• 5.20 E1 – Student Medical Authorization Form

    Exhibit – Student Medication Authorization Form 1,2

    To be completed by the child’s parent(s)/guardian(s). A new form must be completed every school year. Keep in the school nurse’s office or, in the absence of a school nurse, the Building Principal’s office.
    Student’s Name:_________________________________ Birth Date: _____/_____/_____
    Address: ________________________________________________________________
    Home Phone: _______________ Emergency Phone: _______________
    School: ____________________________________ Grade: ________ Teacher:__________

    To be completed by the student’s physician, physician assistant, or advanced practice RN (Note:for asthma inhalers only, use the “Asthma Inhalers” section below):

    Physician’s Printed Name: _____________________________________________________
    Office Address: _____________________________________________________________
    Office Phone: ________________________ Emergency Phone: ______________________
    Medication name: ___________________________________________________________
    Purpose: _________________________________________________________________
    Dosage: _____________________________ Frequency: ___________________________
    Time medication is to be administered or under what circumstances:
    __________________________________________________________________________
    Prescription date: ________ Order date: ________ Discontinuation date: _______________
    Diagnosis requiring medication: ________________________________________________
    Is it necessary for this medication to be administered during the school day ? _____ Yes _____ No
    Expected side effects, if any: ________________________________________________________
    Time interval for re-evaluation: ________________________________________________________
    Other medications student is receiving: _______________________________________________

    Physician’s signature______________________________ Date _______________________

    Asthma Inhalers
    Parent(s)/Guardian(s) please attach prescription label here:

    For only parents/guardians of students who need to carry asthma medication or an epinephrine auto-injector:

    I authorize the School District and its employees and agents, to allow my child or ward to carry and self-administer his or her asthma inhaler and/or use his or her epinephrine auto-injector: (1) while in school, (2) while at a school-sponsored activity, (3) while under the supervision of school personnel, or (4) before or after normal school activities, such as while in before-school or after-school care on school-operated property. Illinois law requires the School District to inform parent(s)/guardian(s) that it, and its employees and agents, incur no liability, except for willful and wanton conduct, as a result of any injury arising from a student’s self-administration of medication or epinephrine auto-injector (105 ILCS 5/22-30).

    Please initial below to indicate (a) receipt of this information, and (b) authorization for your child to carry and use his or her asthma medication or epinephrine auto-injector.
    ____________________
    Parent/Guardian initials

    For all Parents/Guardians:
    By signing below, I agree that I am primarily responsible for administering medication to my child. However, in the event that I am unable to do so or in the event of a medical emergency, I hereby authorize the School District and its employees and agents, in my behalf, to administer or to attempt to administer to my child (or to allow my child to self-administer pursuant to State law, while under the supervision of the employees and agents of the School District), lawfully prescribed medication in the manner described above. This includes administration of undesignated epinephrine auto-injectors or opiod antagonist to my child when there is a good faith belief that my child is having an anaphylactic reaction or opiod overdose, whether such reactions are known to me or not (105 ILCS 5/22-30, amended by P.A. 99-480). I acknowledge that it may be necessary for the administration of medications to my child to be performed by an individual other than a school nurse and specifically consent to such practices, and I agree to indemnify and hold harmless the School District and its employees and agents against any claims, except a claim based on willful and wanton conduct, arising out of the administration or the child’s self-administration of medication.
    __________________________________________________________________________________
    Parent/Guardian printed name
    Address (if different from Student’s above): _____________________________________________
    Phone: _________________________ Emergency Phone: _______________________________
    __________________________________________ ______________________________
    Parent/Guardian Signature Date


    1This exhibit may be placed in the handbook or given to parents/guardians as needed.
    2Students who are diabetic may also self-carry and self-administer diabetic testing supplies and insulin. Diabetic students must have a separate Diabetes Care Plan. For further information, see: www.iasb.com/law/diabmats.cfm, Handbook Procedure 1.130 (Care of Students with Diabetes) and Handbook Procedure 1.130-E1 (Exhibit: Authorization to Provide Diabetes Care, Release of Health Care Information, and Acknowledgement of Responsibilities).
    Cross-references:
    PRESS 7:270, Administering Medicines to Students
    PRESS 7:270-AP, Dispensing Medication
    PRESS 7:270-E, School Medication Authorization