School District: Athens  			   	 School: East Leroy Elementary 			Fax:  (269) 729-9648

AUTHORIZATION FOR THE ADMINISTRATION OF MEDICINE BY SCHOOL PERSONNEL 
Michigan State Law (PA 51 of 2002) requires a written medication order by a physician and parent/guardian written authorization for designated individuals to administer medication to pupils at school. Medications must be in the original properly labeled container and dispensed by a physician/pharmacist.
•	Medication Must be delivered to school office by a Parent       (Students are Not Allowed to Bring in medication)
•	A Separate Authorization Form Must be Completed for Each Medication
•	Parent Assumes Responsibility to Inform the Office of Any Change in Medication	
PRESCRIBER’S AUTHORIZATION
Name of Student: ___________________________________________________ Date of Birth: ________________  Grade:____________
Address: __________________________________________________________________________________________________________
Condition for which drug is being administered: __________________________________________________________________________
Name and Generic name of Drug: _______________________________________ Dose: __________________ Route: ________________
Time of Administration:  Lunchtime    Other. Specify________________________ If “As Needed,” frequency: ___________________	
Relevant side effects:  None expected   Specify: _______________________________________________________________________ 
ALLERGIES:  NO	YES (specify): _________________________________________________________________________________	
Medication shall be administered from: _____________________________________ to ________________________________________ 
(Month / Day / Year) 				(Month / Day / Year) 
Students may self-administer medication such as inhalers for asthma, cartridge injectors for medically-diagnosed allergies, and insulin for diabetes. Some school policies (high school) also allow students to carry non-prescription medication such as non-narcotic analgesics for pain or cramps or antacid tablets such as Tums and prescription medications such as antibiotics for self-administration with the written authorization of an authorized prescriber and written authorization from a student’s parent or guardian or eligible student. 
Prescriber’s authorization for self-administration: 	Yes 	     No

Prescriber’s Name/Title: _____________________________________________________________________________________	 
(Type or print) 
Telephone: _______________________________________________ Fax: _____________________________________________ 
Address: __________________________________________________________________________________________________	
Prescriber’s Signature: ____________________________________________________	 Date: ____________________________		
PARENT/GUARDIAN AUTHORIZATION
I hereby request that the above ordered medication be administered by school personnel and I give permission for the exchange of information between the prescriber and the school nurse necessary to ensure the safe administration of this medication. I understand that I must supply the school with no more than a three (3) month supply of medication.     I understand that this medication will be destroyed if not picked up within one week following termination of the order or the last day of school, whichever comes first.
Parent/Guardian authorization for self-administration: Yes 	No 

Parent/Guardian Signature: _______________________________________________ Date: _______________________ 
Parent’s Home Phone #: ________________________ Cell # ______________________ Work # ___________________________ 

School nurse approval for self-administration:     Yes          No 
School Nurse Signature: _____________________________________________ Date: __________________

Form Revised 8/18 MV