Medication Authorization

AUTHORIZATION FOR PRESCRIBED AND OVER THE COUNTER MEDICATION TEMECULA VALLEY UNIFIED SCHOOL DISTRICT School Year: ________ SCHOOL SITE: ________________________________ FAX# _(951)______________________ Name of Student Date of Birth Grade School PHYSICIAN... More

AUTHORIZATION FOR PRESCRIBED AND OVER THE COUNTER MEDICATION TEMECULA VALLEY UNIFIED SCHOOL DISTRICT School Year: ________ SCHOOL SITE: ________________________________ FAX# _(951)______________________ Name of Student Date of Birth Grade School PHYSICIAN AUTHORIZATION ONE MEDICATION PER FORM I. PRESCRIBED MEDICATION REQUIRED TO BE ADMINISTERED DURING SCHOOL HOURS (THIS SECTION IS TO BE COMPLETED BY PHYSICIAN) Name of medication(s) Health condition for which medication is prescribed Time(s) to be taken Dosage Route of administration Precaution-possible untoward reactions Date to be discontinued Special storage instructions Name of physician (Please print) Physician’s telephone number Fax number ( ) ( ) Physician’s signature Date II. THIS SECTION IS TO BE COMPLETED BY PARENT/GUARDIAN (Parts I AND II MUST BE COMPLETED) NO MEDICATION WILL BE ADMINISTERED WITHOUT THE REQUIRED SIGNATURES THIS FORM MUST BE RENEWED AT THE BEGINNING OF EACH SCHOOL YEAR OR Medication. Medication Authorization Less