Williamsburg Comm. School District
Student’s Name Grade Homeroom teacher
School medications and health care services are administered following these guidelines:
Parent signed and dated authorization to administer medication
Doctor’s signature if medication given longer than two (2) weeks
The medication is in the original labeled container as dispensed or the manufacturer’s labeled container
The medication label contains the student’s name, name of the medication, directions for use and date
Annual renewal of authorization and immediate notification, in writing, of any changes
Significant Information/instruction
Reason for Medication
Length of time Medication to be given at school
Doctor Date Phone Number
I request the above student be given the medication at school and school activities by qualified staff, according to the prescription or non prescription instructions and a record maintained. The student has experienced no previous side effects from the medication. I further agree that school personnel may contact the prescriber as needed and that medication information may be shared with school personnel who need to know.
I agree to provide safe delivery of medication and equipment to and from school and to pick-up remaining medication and equipment as requested or it will be properly destroyed.
Parent/Guardian Signature: __________________________________ Date: ____________