LIBERTY SCHOOL DISTRICT, #362
S. 29818 North Pine Creek Road
Spangle, WA 99031
Bill Motsenbocker, Superintendent
Liberty Elementary/Junior High
Bill Motsenbocker, Principal
Telephone: (509) 245-3211
Fax: (509) 245-3530
Liberty High School
Aaron Fletcher, Principal
Telephone: (509) 245-3229
Fax: (509) 245-3205______
Authorization for Administration of Oral Medication at School
Student Name: _________________________________________Birthdate:_____________
School: ________________________________Teacher/Grade: _______________________
…………………………………………………………………………………………………………………..
THIS PORTION TO BE COMPLETED BY LICENSED HEALTH PROFESSIONAL WITH
PRESCRIPTIVE AUTHORITY
Name of Medication:_____________________Strength:_______________Dosage: __________
Method of Administration: ___________________ Time of Day to be given: _________________
If to be given as needed (prn), specify minimum length of time between doses:_______________
Diagnosis: _____________________________________________________________________
Possible side effects of medication: __________________________________________________
Emergency procedure in case of serious side effects: ___________________________________
I request and authorize that the above named student be administered the above identified oral
medication in accordance with the instructions indicated above from ____________ to
_________(not to exceed the current school year). There is a valid reason which makes the
administration of this medication necessary during school hours.
Date of Signature:_________________
Signature: ____________________________________
Telephone #: _________________ Fax #: ________________Print Name: __________________
…………………………………………………………………………………………………………………
THIS PORTION IS TO BE COMPLETED BY A PARENT/GUARDIAN
I request and authorize the Liberty School District to administer the above ordered medication for my student in
accordance the directions given from __________________ to ________________(not to exceed the current school
year). Medication will be supplied to the school in the original container with the pharmacy label attached which
includes the student’s name, medication, dosage and time to be given.
I will allow my student to carry their own inhaler: Yes____
No ____
My student is trained to self-administer their own emergency injectable medication. Yes _____ No_____
Date of Signature: _____________ Parent/Guardian Signature:____________________________
Home Phone #: _____________________________ Work/Cell Phone#: ____________________
LIBERTY SCHOOL DISTRICT # 362
S. 29818 North Pine Creek Road
Spangle, WA 99031
(509) 624-4415
Parent Information on Medication at School
In accordance with Washington State law, administration of oral medication may be provided at
school if all conditions are met. Medication is ordered to be given to a student at school only when
necessary. Whenever possible, the parent and physician are urged to design a schedule for giving
medications outside of school hours. If this is not possible, it is understood by the parent that the
medication will be dispensed by the school nurse, the principal or his/her designee. Only
medications with completed Medication Authorization forms will be dispensed. The principal will
designate the person responsible for giving medications on an individual basis. The school
accepts no responsibility for untoward medication reactions when the medication is dispensed in
accordance with the physician’s directions. It is the parent’s responsibility to maintain the supply of
medication. The medication authorization is valid only for the current school year and must be
renewed annually. The parent also understands and agrees that it is possible, because of the
school schedule and other responsibilities, a dose or dosages may be delayed or missed. In such
instances, the parent will be notified before a delayed medication is given or if a medication
dosage is missed.
All Medication
Must be brought to the school office by the parent and not the student.
Pills need to be broken or cut prior to being brought to school for half doses.
Medication will be counted by the school staff and parent, and the acceptance log signed by
both for all medication brought to school.
Medication left at school will be destroyed on the last day of school, unless previously picked
up or arranged between the parent and the school nurse.
Prescription Medication
An Authorization for Administration of Oral Medication at School form must be
completed and signed by the parent and a licensed health professional prescribing within
the scope of his/her prescriptive authority.
All medication must be in the original prescription bottle and properly labeled with the
student’s name, name of medication, exact dosage, name of prescribing licensed health
professional, the date and time of day to be given.
The directions on the Authorization form must match the directions on the prescription label.
Sample medication must also be properly labeled and in the original container or package.
Non-Prescription Medication
(e.g. – cough drops, vitamins, aspirin, Tylenol or any other over-the-counter medication)
An Authorization for Administration of Oral Medication at School form must be
completed and signed by the parent and the licensed health professional prescribing
within the scope of his/her prescriptive authority.
No medication shall be given without this Authorization form.
Non-prescription medication must be in its original package and must be labeled by the
parent with the student’s name.