MEDICATION AUTHORIZATION FORM
SPEED S.E.J.A. #802
1125 Division Street - Chicago Heights, IL 60411
Phone (708)________________ Fax (708)________________ School Year ________
MEDICATION AUTHORIZATION FORM
Permit for SPEED Personnel to Administer Required Mediations during School Hours
Student Name __________________________________________ School ___________________
(TO BE COMPLETED BY LICENSED PRESCRIBER)
Date __________________________
This student____________________________________________________________________ is under my medical care for
________________________________________________________________________________ and medication is required
during the school day for the purpose of _____________________________________________________________________
| | | |Time To Be Given At | | |
|Name of Drug |Dosage |Frequency |School/ Education Setting|Duration |Side Effects |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
Signature of Licensed Prescriber _______________________________________
Printed Name of Licensed Prescriber ____________________________________
Address __________________________________________________________
_________________________________________________________________ (City) (State) (Zip Code)
__________________________________________________________________ Telephone Number Fax Number
(TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN)
I, _______________________________________, give permission for my child to receive the above medication(s) as directed by the licensed prescriber. The medication will be sent to school/educational setting in a container appropriately labeled by the pharmacy. I will notify the school in writing if the medication is discontinued. I will also obtain a written order from the licensed prescriber if the medication dosage is changed. I will bring the medication to the school nurse or notify the school nurse if extenuating circumstances exist regarding transport of medication to the educational setting.
Parent/Guardian Signature_____________________________________ Date_________________________
Address/City/State________________________________________________________________________
Home phone ____________________________ Cell/Work Phone _________________________________
SPEED: Stu-030
6/07
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