Medication Administration Authorization Form - Boulder Valley School District
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1Health Services
BOULDER VALLEY SCHOOL DISTRICT RE-2
SCHOOL HEALTH PROGRAM
MEDICATION ADMINISTRATION AUTHORIZATION
The undersigned parent(s) or guardian(s) of _______________________________________________________
hereby request personnel employed by the Boulder Valley School District RE-2 to see that said child receives
__________________________________________ at ________as described by prescribing health care provider.
(name of medication)
(time)
It is required by the Boulder Valley School District as a condition to its agreement to administer any medication,
that the medicine has been prescribed by a health care provider and that it has been furnished by the parent(s) or
guardian(s) of the student with an appropriate label stating the child’s names, name of the medicine, times at
which medication is to be administered, the dosage and the date when the medication is to be stopped. It is
understood that the medication is administered solely at the request of and as an accommodation to the
undersigned parent(s) or guardian(s). In consideration of the acceptance of the request to perform this service by
any personnel employed by the Boulder Valley School District RE-2, the undersigned parent(s) or guardian(s)
hereby agree(s) to release the said institution and their personnel from any legal claim(s) which they now have or
may hereafter have arising out of the administration of (or failure to administer) the medication to the student.
Dated this ____________________________day of ___________________ 20___________.
__________________________________________
_______________________________________
Name of Health Care Provider prescribing medication
School child attends
______________________________________________
Signature of Parent or Guardian
HEALTH CARE PROIVDER’S SIGNED ORDER FOR MEDICATION AT SCHOOL
Student’s Name _________________________________________Medication ____________________________
Route of administration __________________________Dosage (total mg/dose)___________________________
to be given at ______________________from _______________________to ___________________________.
(time)
(date)
(date)
Purpose of medication __________________________________________________________________________
Possible side effects ___________________________________________________________________________
__________________________________________________________
__________________________
Health Care Provider’s Signature
Date
For inhalers & EpiPens only: Provider, please sign below to give permission for student to carry and self-
administer the inhaler and/or EpiPen ordered on this form.
________________________________
Health Care Provider’s Signature & Date
Jan 2012, Revised August 2014
Medication Section Page 6
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