Provider and Parent Permission to Administer Medication 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'School Name' and 'School Year' at the top of the form. Specify whether the medication is for routine or as needed (prn).
3. Enter the child's name, date of birth, grade, and teacher's name in the designated fields.
4. In the 'Medication Name' section, write down the specific medication being administered. Ensure you only list one medication per page.
5. Complete the dosage, route, diagnosis/reason for medication, time due, frequency, and ICD 10 code fields accurately.
6. Indicate any severe allergies and side effects that may occur. This information is crucial for safe administration.
7. Have the prescribing healthcare provider sign and provide their address. Confirm if it's a controlled substance and note how many days it will be given at school.
8. Finally, have a parent or guardian complete their section by signing and providing their printed name and contact information.

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