Hull Public Schools
Parent/Guardian Authorization for Prescription Medication Administration
Student’s Name: ____________________________Date of Birth: ____________
Parent/Guardian Name: _______________________________________________
Telephone Number, Home: ____________________Work: ___________________
Telephone Number, Emergency: _________________________________________
Other person (s) to be notified in case of medication emergency:
Name: ____________________________________Telephone: _________________
My son/daughter is currently receiving the following medication:
______________________________________________________________________
My son/daughter has the following food or drug allergies:
_________________________________________________________________________
I consent to have the school nurse or school personnel designated by the school nurse to administer the medication prescribed by:
__________________________________to _________________________________
Licensed Prescriber Student’s Name
I give permission for my son/daughter to self-administer the medication if the school nurse determines it safe and appropriate. __________Yes __________No
I give permission to the School Nurse to share information relevant to the prescribed medication administration as he/she determines appropriate for my child’s health and safety.
I understand I may retrieve the medication from the school at any time; however, the medication will be destroyed if it is not picked up within one week following termination of the order or one week beyond the close of school.
Parent/Guardian Signature: _______________________________Date: __________
Relationship to Student: _________________________________________________
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