Theloganschool.org

Medication Authorization Release Form
(To be signed by parent/guardian and physician)

By signing this form, I hereby the Logan School for Creative Learning to administer any medication indicated below, be it over the counter or
prescription medication, to my child. I understand that my child may not be given any medication if this form is not signed by me and my child’s
physician. I also recognize that it is my job as the parent/guardian to supply all prescription medication in its original, pharmacy container. I
understand that I will be notified to pick up medications if the medication is expired, the school year ends, or the student withdraws. All student
specific medication(s) that are left at the school will be discarded according to the Colorado Board of Pharmacy recommendations. I am authorizing for: Student Name: ___________________________________ DOB: ________________ Teacher: ____________________
Preventative Over the Counter Medications (OTC)
(Check only the boxes for the medications you are authorizing The Logan School to administer.)

□ Neosporin □ Cough Drops □ Topical lotion □ Sunscreen

Generic Medications for Treatment, permission valid for 2012/2013 school year (start-stop date 8/2012-6/2013)
□ Acetaminophen Dosage: _______________ (circle) Jr. or Adult every __________ hours as needed for: ___________________________
Dosage: _______________ (circle) Jr. or Adult every __________ hours as needed for: ___________________________ □ Decongestant ______________________ Dosage: _________ (circle) Jr. or Adult every ______hours as needed for: ________________ □ Diphenhydramine/Benadryl Dosage: _______________ (circle) Jr. or Adult every ___________ hours as needed for: ________________ □ Pepto-Bismol Dosage: _______________ (circle) Jr. or Adult every ___________ hours as needed for: __________________________
□ Dramamine/Bonine Dosage: ___________ (circle) Jr. or Adult every ___________ hours as needed for: __________________________
□ Give my child no medication

Prescriptions Authorized to Administer must be labeled with child’s name. Dosage must match the signed health care provider
authorization, and medicine must be packaged in original container.

______________________________ Dosage: ____________ Route: ________ Time: ________ start-stop date__________________
______________________________ Dosage: ____________ Route: ________ Time: ________ start-stop date__________________
______________________________ Dosage: ____________ Route: ________ Time: ________ start-stop date__________________
Known Allergies are: _________________________________________________________________ * see allergy form to expand on details
Dietary Restrictions are: ____________________________________________________________________________________________
It is understood that the medication is administered solely at the request of, and as an accommodations to, the undersigned parent/guardian. In
consideration of the acceptance of the request to perform this service by an authorized person by the Logan School for Creative Learning, the
undersigned parent/guardian hereby agrees to release the Logan School for Creative Learning and its personnel from any legal claim which they now have or may hereafter have arising out of the administration of or failure to administer the medication to the student. Self Carry Medication for Emergency EpiPen and/or Inhaler
May Self Carry Medication ______ Health Care Provider Initials_______
Printed name of Parent/Guardian ________________________ Signature: ____________________________ Date: ______________ Home phone: ________________________ Work phone: ________________________ Cell phone: ________________________ Printed name of Physician/Health Care Provider: ______________________________ Phone: ________________________ Signature of Physician: ______________________________ Date: ______________ License # _____________________

Source: http://www.theloganschool.org/inde_downloads/summer%20packet/2012-13%20Medication%20Authorization%20Release%20Form.pdf