UNIVERSITY HIGH SCHOOL

SCHOOL MEDICATION AUTHORIZATION FORM

TO BE COMPLETED BY LICENSED PRESCRIBER:

Student’s Name_________________________________________ Birth date_______________________

Name of Medication:_____________________________________________________________________

Dosage_______________________ Frequency_______________ Time to be given in school _________

Date of prescription:______________ Date of Order ______________ Discontinuation Date___________

Diagnosis requiring medication_____________________________________________________________

Intended effect of this medication___________________________________________________________

Must this medication be administered during the school day in order to allow the child to attend school or to address the student’s medication condition? _______ Side effects, if any _________________________

Time interval for re-evaluation_____________Other medications student is receiving _________________

Prescriber’s Signature ____________________________________________________________________

Prescriber’s name (please print) ____________________________________________________________

Address _______________________________________________________________________________

Phone ___________________ Emergency Phone _______________________ Date ________________

TO BE COMPLETED BY PARENT OR GUARDIAN:

I confirm that I am primarily responsible for administering medication to my child. However, in the event that I am unable to do so or in the event of a medical emergency, I hereby authorize University High School and its employees and agents, in my behalf and stead, to administer or to attempt to administer to my child (or to allow my child to self-administer, while under the supervision of the employees and agents of University High School), lawfully prescribed medication in the manner described above. I acknowledge that it may be necessary for the administration of medications to my child to performed by an individual other than a school nurse, and specifically consent to such practices. I further acknowledge and agree that, when the lawfully prescribed medication is so administered or attempted to be administered, I waive any claims I might have against the school, its employees and agents arising out of the administration of said medication. In addition, I agree to hold harmless and indemnify the school, its employees and agents, either jointly or severally, from and against any and all claims, damages, causes of action or injuries incurred or resulting from the administration or attempts at administration of said medication.

Parent or Guardian Signature _____________________________________________________________

Parent or Guardian Name (please print) ______________________________________________________

Address _______________________________________________________________________________

Home Phone ________________________ Work Phone _______________________________________

Date ________________________________