Authorization for Administration of Medication in School
Queen of Peace Catholic School
Authorization to Administer Medication 2020-2021
Student’s Name___________________________ Birthdate______________________
Address_________________________________ Phone Number_________________
Name of Parent/Guardian ___________________________________________________
Parental Release
I request and authorize designated school personnel to give the following medication to my child as prescribed by a physician. I release school personnel from any liability should reactions result from the medications. I authorize the school nurse to contact the prescribing physician’s office and allow his/her office to disclose the necessary information regarding this/these medications.
_________________________________________ ____________________
Parent Signature Date
Note: All medication must be in original container, properly labeled, including a recent date.
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To be completed by physician:
Medical Diagnosis_________________________________________________________
Name of Medication Dosage Time to be Given
________________________ ___________ _______________________
________________________ ___________ _______________________
Side effects of medication __________________________________________________
It is acceptable for student to carry inhaler on self and self-administer as directed:
(Inhaler use ONLY) ______ YES ______NO
_________________________________ ________________
Physician Signature Date
_________________________________ __________________________________
Clinic Address/Phone
102 4th Street - Cloquet, MN 55720 - (218) 879-8516
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