Solano County Office of Education

WOODLAND JOINT UNIFIED SCHOOL DISTRICT

AUTHORIZATION FOR MEDICATION ADMINISTRATION This form must be completed with prescribing authorized health care provider and parent/guardian signatures before any medication can be administered at school.

California Education Code 49423 allows the school nurse or other designated school personnel to assist students who are required to take medication during the school day. This service is provided to enable the student to remain in school and to maintain or improve the potential for learning. Medication must be in the container in which it was purchased with the pharmacy or manufacturer’s label attached and must be prescribed to the student to whom it will be administered. No medications (including over-the-counter medications) will be given at school without a current authorized health care provider prescription.

Student name Birthdate Teacher/Grade TO BE COMPLETED AND SIGNED BY AUTHORIZED HEALTH CARE PROVIDER: Diagnosis: Medication Prescribed (Name/strength): Dosage: Times: Route: Length of time to be taken: Side effects: Signs & symptoms indicating need to give PRN(as needed) medication: Minimum interval for PRN medication: Potential emergency situations: It is necessary for this medication to be taken during the school day at the time(s) indicated above. PLEASE SIGN AND CHECK THE BOX BELOW TO AUTHORIZE SELF ADMINISRATION OF THIS MEDICATION. Medical provider’s signature: Date:  I have instructed this student in the proper use of his/her emergency medication. It is my professional opinion that this student be allowed to carry this medication on his/her person and self administer it as needed. Medical provider’s name: License No.: Address: Fax______Phone:

TO BE COMPLETED BY PARENT/GUARDIAN: My signature below verifies that: 1. I am the parent or legal guardian of the pupil named hereon. 2. I authorize school personnel to administer the above medication to my child as ordered by the above health care provider. 3. I understand the school is not legally obligated to administer medication to any pupil; therefore, I agree to hold the Woodland Joint Unified School District harmless from any and all liability resulting from the administration of the medication in the manner directed. 4. I understand that information regarding this medication and the condition for which it is prescribed will be shared with the staff involved in the safety and education of my student. 5. I give my permission for the exchange of confidential information between Woodland Joint Unified School District and the above named health care provider as it relates to this medication prescribed for my child.

Parent/Guardian signature: Phone Date: Address: Home Phone: Work Phone:

A new authorization form must be completed whenever the prescription changes and at the beginning of each school year. Expiration Date of Medication

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