Medication Authorization Form

Policy Code: 
Adoption Date: 
Tuesday, September 25th, 2012
Review Date: 
Tuesday, October 28th, 2014



To:  Principal of ______________________________    School       Date_________________



We the parents/guardians of _____________________________would like to request that medication be given to our child at school according to the directions specified below by our physician.  We report that the medication in the container and the label have not been tampered with.  We recognize that this is only a request and school officials may choose to honor or reject this request at their option.  We release any and/or all school personnel from any liability that could be brought about by inadvertent failure to give our child the medication as indicated, or by any accidental overdose.


____________________________________       ____________________________________

Parent/Guardian                                                               Parent/Guardian


The following medication is recommended to be given to ______________________________
while he or she is at school or attending school activities.

            Name of Medication                                 Dosage/Route                           Time to be Given

1.  ___________________________       ________________________       _______________

2.  Side Effects:______________________________________________________________

3.  Number of school days for which the need for medication is anticipated_________________

Please Circle:

Yes       No       Would this medication be dangerous if taken by any person other than the one
                        for whom it was prescribed?

Yes       No       Does this medication require storage under refrigeration?

Yes       No       Would this medication prevent the child from participation in field trips or other
                        school activities?

Yes       No       Is any of this medication specifically for seizure control?

Instructions in case of seizure____________________________________________________





                                                                                                   Signature of Physician


Request Accepted________    Denied______________    (If denied, please state reason on the

 reverse of this form.)


____________________________________       ____________________________________

Signature of School Principal                                      Signature of School Nurse


 Signature of Assigned School Person


Non-Discrimination Statement

Iron County School District is committed to a policy of equal employment opportunity and does not discriminate in the terms, conditions, or privileges of employment on account of race, age, color, sex, national origin, physical or mental disability, or religion or otherwise as may be prohibited by federal and state law.

School District Office

Hours 8 a.m. - 5 p.m. Mon.- Fri.
2077 W. Royal Hunte Dr.
Cedar City, Utah 84720
PH 435.586.2804  FAX 435.586.2815