CONCORD PUBLIC SCHOOLS
CONCORD-CARLISLE REGIONAL HIGH SCHOOL
PARENT/GUARDIAN
AUTHORIZATION FORM
FOR
PRESCRIPTION AND NON-PRESCRIPTION MEDICATION ADMINISTRATION
Name of
Student____________________________ Date
of Birth____________
Address__________________________________________ Grade____________
(street) (city/town)
Parent/Guardian printed
name_______________________________________________
Telephone
Number – Home:________________________
Telephone
Number – Work: ________________________
Telephone
Number – Emergency: ___________________
Other
person(s) to be notified in case of medication emergency
My son/daughter is currently receiving the following
medications (to be completed if not in violation of confidentiality):
______________________________________________________________________
My son/daughter has the following food or drug allergies:
_______________________________________________________________________
I consent to have the School Nurse or school personnel
designated by the School Nurse administer the medication prescribed by:
________________________________ to _____________________________
Licensed Prescriber Student
Name
I give permission for my son/daughter to self-administer
medication, if the school nurse determines it is safe and appropriate.
_______YES _______NO
I give permission to the school nurse to share information
relevant to the prescribed medication administration as he/she determines
appropriate for my son’s/daughter’s health and safety.
I understand I may retrieve the medication from the school
at any time, however, the medication will be destroyed if it is not picked up
within one week following termination of the order or one week beyond the close
of school.
Parent/Guardian Signature____________________________ Date_________
Relationship to student_______________________________
Address: __________________________________________
______________________________________