Marshall County Schools Health Services
AUTHORIZATION TO DESPENSE MEDICATION

Child's Name _________________________________________________________

Name of Medication ____________________________________________________

Name of Physician _____________________________________________________

Telephone Number of Physician __________________________________________

Time to be Administered ________________________________________________

Dosage ______________________________________________________________

Possible Side Effects ____________________________________________________

Termination Date for Medication __________________________________________

**Please note times for administration for medications. Some can be given at home.

_____________________________________________________	________________
Signature of Parent or Guardian	Date
______________________________________________________	________________
Signature of Physician	Date

**Physician's signature required for all prescription medications and any other medication that is given for five or more days.

**AN ADULT MUST BRING MEDICATIONS IN LABELED BOTTLE. NO MEDICATIONS ALLOWED ON SCHOOL BUSES.

** PLEASE FILL OUT FORM COMPLETELY AND RETURN TO SCHOOL.