STUDENTS
507-2E2- PARENTAL AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF PRESCRIPTION MEDICATION TO STUDENTS
The undersigned are the parent(s), guardian(s), or person(s) in charge of
(Student's Full Legal Name) ,
in the grade at the building in the WACO Community School District.
It is necessary that ______________________ receive
(name of medication) ___________________________________________________________ ,
beginning on (date) and continuing through (date) .
I hereby request the WACO Community School District, or its authorized representative, to administer the above-named medication to my child named above and agree to:
1. Submit this request to the principal or school nurse;
2. Personally ensure that the medication is received by the principal or school nurse administering it in the container in which it was dispensed by the prescribing physician or licensed pharmacist or is in the manufacturer's container;
3. Personally ensure that the container in which the medication is dispensed is marked with the medication name, dosage, interval dosage, and date after which no administration should be given; and
Dated this day of , 20_____
Name of Student
Parent/Guardian Home Phone Number
_____________________
Alternate Phone No.
Reviewed: 10/16/2023