Rose Tree Media School District
Student Medication Authorization Form
Student Name: _____________________________________________________ Date: _________________
School: ______________________________________ Grade/Teacher: ______________________________
All medication(s) should be given at home before and/or after school whenever possible. If medication must be
given during school hours the following criteria must be met. In accordance with new guidelines from the
Pennsylvania Department of Health, starting September 2010 ALL medications, both prescription and
over the counter, must be accompanied by a written, signed order from a licensed prescriber. In addition,
the parent/guardian must sign the RTMSD Student Medication Authorization form for each medication to be
administered in school. The exception is acetaminophen and ibuprofen, as these medications are covered by a
standing order and permission to administer can be granted on the Student Emergency Card. Prescription
medication must be in a current pharmacy container with directions for administration from the physician and
all over the counter medications must be in their original container. Orders and medication authorization forms
must be renewed every school year and any time there is a change in dosage or medication.
Parent/Guardian Consent:
I give permission for my child _____________________________________________to receive the following
medication, ______________________________________, ordered by a licensed prescriber for administration
during the school day and/or on school sponsored field trips. I have completed the Instructions for
Administration section listed below.
I/We do hereby waive, release, discharge, indemnify and/or hold harmless the said employee and School
District from any and all liability for any reaction, injury, harm, and/or damage which may be caused to my/our
child by reason of administering the said medication pursuant to my/our authorization herein including but not
limited to negligent acts or omissions.
Parent/Guardian Signature: ________________________________________________ Date: ______________
Parent/Guardian Name Printed: ________________________________________________________________
Instructions for Administration
Medication: _______________________________________________________________________________
Dosage: __________________________________________________________________________________
Time of Administration: _____________________________________________________________________
MEDICATION ADMINISTRATION RECORD
ROSE TREE MEDIA SCHOOL DISTRICT
Name___________________________________________________________ Grade_____________________
Diagnosis___________________________________________________________________________________
Medication_______________________________________________________ Dosage____________________
Time of Administration_____________________________________________ Order Date_________________
Month September
October
November
December
Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Full Signature and Initials__________
_______________________________
_______________________________
_______________________________
_______________________________
Key: A
Absent
HD
Half Day
NS
No School
O
No Medication
Comments:
January
February
March
April
May
June