Medication Authorization & Release (2026-2027)

FORREST CITY SCHOOL DISTRICT

MEDICATION AUTHORIZATION AND RELEASE
Note: A separate form must be completed for each medication administered.
MEDICATION IS TO BE BROUGHT TO THE SCHOOL BY AN ADULT. CHILDREN ARE NOT TO BRING THEIR OWN MEDICATION.

Medication must be in the current original container from the pharmacy. Medication will only be administered according to the Doctor's directions on the container.
Student Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade
School Building
Homeroom Teacher
Hospital to be called
Hospital Phone:
Format: (000) 000-0000.
Doctor to be called
Doctor Phone:
Format: (000) 000-0000.
Name of Medication
Reason(s) for Medication
Dosage to be taken
Time to be Taken
Parent(s) Phone Number: Home
Please enter a valid phone number.Format: (000) 000-0000.
Work
Please enter a valid phone number.Format: (000) 000-0000.
Cell
Please enter a valid phone number.Format: (000) 000-0000.
In case of emergency call
Emergency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I certify that at least one dose of the medication has been previously given and NO adverse reactions were experienced. Therefore, I give permission for the school nurse, school principal, or person designated by the principal to administer the above medication to my child. Parent or Guardian
Parent or Guardian

In consideration of the above action by the school employee, I hereby waive, release and relinquish any claim which I might have individually or on behalf of my child against the above named school employees arising out of the administration of the medication or the supervision thereof. The school has permission- to contact the prescribing physician for information relating to this medication. The school nurse (or designee) has my permission to take a photo of my child and place it on his/her medication envelope for identity purposes. I hereby authorize the school nurse or his/her designee to administer the above mentioned medications to my child. I acknowledge that the District, its Board of Directors, and its employees shall be immune from civil liability for damages resulting from the administration of medications in accordance to this consent form.

Parent or Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
NOTE: Medications including self-administration brought to the school must be in the original container and properly labeled with the student's name, the ordering provider's name, the name of the medication, the dosage, frequency, and instructions for the administration (including times). Additional information accompanying the medication shall state the purpose for the medication, it's possible side effects, and any other pertinent instructions including storage requirements or warnings. Medication brought in any other wrapper or container will not be administered. Parents of elementary school students are responsible for bringing medication safely to and from school. Medication will not be sent home with the student. Parents must plan to pick it up.
Date   Medication   Strength   # of Pills   Signature
Date   Medication   Strength   # of Pills   Signature
Date   Medication   Strength   # of Pills   Signature
Date   Medication   Strength   # of Pills   Signature
Date   Medication   Strength   # of Pills   Signature

Rows	Date	Medication	Strength	# of Pills
1
2
3
4
5
6
7
8
9
10

Should be Empty:

FORREST CITY SCHOOL DISTRICT