St. Anselm School - Authorization to Administer Medication 2022-2023

Student*

First NameLast Name
Email*
example@example.com
Grade
Teacher

First NameLast Name
Date

MonthDayYear
Date
Parent

First NameLast Name
Phone Number
Please enter a valid phone number.
Health care provider
Dose
Frequency
Duration
Possible side effects
Additional Information and/or Precautions regarding medications or student's condition:
I am the parent/guardian of th.e above student and I have lawful custody of said child. I hereby give consent to appropriate Dir,;trict personnel to administer or assist in administering medication( s) and/or treatment as specified by his/he:i:health.care .provider. Furthern:for, I hereby give consent to the District to receive from, or send to, the health care provider any in.formation concerning my child's medical condition.
Parent Signature

Clear
Date

MonthDayYear
Date
Complete this section for medications which student may self-administer:
AUIBORIZATION FOR SELF-ADMINISTRATION:

Student: I certify that I have read and understand the instructions regarding the
self-administration ofmy medications(s). I agree to take these above described medications in compliance with. my health care provider's recommendations.

Student Signature   Date

Parent/Guardian: My child has been instructed in the proper dosage and administration of th.e above medication and has demonstrated the 􀂑bility to self-administer it. We/I
(Parent/Guardian) request that s/he be permitted to self-administer it as directed by our health care provider in ·compliance with District policy and procedures.

Parent/GuardianSignature   Date

HEALTH CARE PROVIDER: I am a physician actively licensed by the state of California.
Attached hereto is a prescription for the medication/treatment specified above.
( ) Initial here if student has been properly trained and is able to self-administer
r
PHYSICIANSignature   Date
Should be Empty:

Complete this section for medications which student may self-administer: