Medication authorization form
A form for a school, camp or daycare to give a child medication: drug, dose, times, prescriber and parent permission.
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Use your program's form if it has one
This is a general template, not legal advice. Not medical advice. Share with your doctor. State law and school district policy decide who may give medication, whether a prescriber must sign, and when a student may carry an inhaler or epinephrine. Many schools accept only their own form, so ask the school nurse or camp director first.
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Medication Authorization Form
Lakeview Elementary School
| Program | Lakeview Elementary School, Austin, TX | ||
|---|---|---|---|
| Child's name | Riley Lee | Date of birth | |
| Grade, class or group | Grade 3, Ms. Kim | ||
| Medication and strength | Albuterol HFA inhaler, 90 mcg per puff | ||
| Dose | 2 puffs | Reason | Asthma |
| How given | □ By mouth ■ Inhaled □ Injection □ On the skin □ Eye or ear drops □ Nasal spray □ Other | ||
| Time or symptoms | As needed for cough, wheezing or shortness of breath, no more than every 4 hours. 15 minutes before PE. | ||
| Dates | August 17, 2026 to May 28, 2027 | ||
| Possible side effects | |||
| Prescriber (name, phone) | Dr. Taylor Kim, Lakeview Pediatrics, (555) 010-0003 | ||
| Parent or guardian (name, phone) | Jordan Lee, (555) 010-0000 | ||
Parent or guardian authorization
- 1. I ask that Lakeview Elementary School staff give Riley Lee the medication described above, as directed on this form.
- 2. An adult will bring the medication in its original container. Prescription medicine has the pharmacy label with the child's name, the drug, the dose and the prescriber. Over-the-counter medicine is in its original package and is given only as the label or the prescriber directs.
- 3. I will tell Lakeview Elementary School in writing right away if the dose, time or medication changes. A change needs a new form. This form is good only for the dates above and must be renewed at least once a year.
- 4. I will pick up unused or expired medication by the end date. Medication left after that may be destroyed.
- 5. I agree that Lakeview Elementary School may share information about this medication with staff who need to know it and, in an emergency, with responders.
Parent or guardian signature: ______________________ Date: ____________
Printed name: Jordan Lee
Prescriber order
I prescribed the medication above for Riley Lee for the reason and on the schedule shown, and it is safe for program staff to give it as directed.
Prescriber signature: ______________________ Date: ____________
Printed name and license type: Dr. Taylor Kim
Phone or fax: ______________________
Self-carry: asthma inhaler or epinephrine auto-injector
- 1. Parent: I ask that Riley Lee be allowed to carry and use this medication on their own. My child knows when and how to use it. The device has the pharmacy label and is not expired. I will give the program a spare if it asks for one.
- 2. Prescriber: This student has been taught to use the medication and is able to carry it and use it without help.
- 3. Student: I will keep my medication with me, not share it, and tell an adult right away after I use my epinephrine, or if my inhaler does not help.
Prescriber signature: ______________________ Date: ____________
Student signature: ______________________ Date: ____________
| For program use | Received by: ______________________ Date: ____________ Amount received: ____________ |
|---|
How to use it
Enter the program, the child and the medication exactly as the pharmacy label shows it, with the dose, how it is given and when. For an as-needed medicine, write the symptoms and how often it may be repeated. Add the prescriber and your phone number. Turn on the prescriber section if the medicine is a prescription, and the self-carry section if your child should keep an inhaler or epinephrine with them.
Sign it, have the prescriber sign their part, and bring the form with the medicine in its original labeled container. Do not send medicine in a backpack.
Things to watch
Most schools want a new form every school year and whenever the dose changes. For self-carry, the rules on who must sign come from your state and district, and many schools also ask for a spare device kept in the office. Attach an asthma or allergy action plan if the doctor gave you one.
Calculators that go with this
Frequently asked questions
Do I need a doctor's signature for over-the-counter medicine?
It depends on the program. Many schools accept a parent signature alone for over-the-counter medicine in its original package, while others want a prescriber's order for every medicine. Child care centers often follow state licensing rules. Ask before you send it.
Can my child carry an inhaler or EpiPen at school?
Most states have laws that let students carry asthma or allergy medicine under some conditions, usually with a prescriber's order and a parent's permission. Use the self-carry section and check your district's policy for anything else it needs.
Does the same form work for camp?
Yes. Type the camp name as the program and use the session dates as the start and end. Overnight camps may also ask for a full daily medication schedule, so list each time in the time box.
Is what I type saved anywhere?
No. Everything stays in your browser and nothing is sent to our server. If you refresh the page it is gone, so print, save a PDF or download the DOCX when you are done.