Madison Central School District
7303 Route 20 Madison, New York 13402
AUTHORIZATION FOR ADMINISTRATION OF MEDICATION
A. To be completed by the Licensed Health Care Prescriber:
I request that my patient, as listed below, receive the following medication:
Name of Student: ________________________________ Date of Birth: __________________
Name of Medication: ___________________________________________________________
Prescribed dosage and route of administration: ________________________________________
Frequency and time to be taken during school hours: ___________________________________
Duration of treatment: _________________________________________________________
For PRN medications - list conditions under which medication should be administered:
Name of Licensed Prescriber & Title (please print): ___________________________________
Prescriber's signature: ______________________________ Date: ______________________
Issuing Physicians Office: __________________________ Phone: ______________________
B. To be completed by parent or guardian:
I request that my child ___________________________________ grade _________________
receive the medication as prescribed above by a our licensed health care prescriber. The medication is to be furnished by me in the properly labeled original container from the pharmacy. I understand that the school nurse, or other designated person in the case of the absence of the school nurse, will administer the medication.
I also hereby request that my child's teacher or other designated faculty member administer the medication on such school-sponsored activites such as field trips, athletic events, etc. during the ______________ school year.
The above medication is to be administered during the current school year or ountil terminated by written notice.
Signature of Parent/Guardian: ____________________________________________________
Phone (home): ________________________ Phone (work): ___________________________