AUTHORIZATION FOR PRESCRIBED MEDICATIONS
Florida Statue 1006.062
Health Services Department
1614 SE Fort King Street Ocala, FL 34471
(352) 671-7700 (352) 671-7788 www.marionschools.net
FRS (800) 955-8770 (800) 955-8771 (TTY)
Place
School: Student
Photo
Request Beginning (Date): To: Here
Not to exceed one (1) school year Form must be renewed each school year
Student: Student #: Date of Birth:
Physician Ordering Medication: Physician Phone: Grade:
Student Allergies:
Health Conditions Requiring Medication: (Diagnosis)
Parent/Guardian: Contact #:
PLEASE PRINT
Second Contact Person: Contact #:
PLEASE PRINT
MEDICATION ORDER – ALL INFORMATION MUST MATCH THE PRESCRIPTION LABEL
All medication must be properly labeled and in most current original containers. Complete one form for each medication to be administered.
A new form must be completed any time the dosage changes.
Name of Medication: Expiration Date:
Dosage (strength): Route of Administration:
Amount to be Given: Time(s) to be Given at School:
Special Instructions:
AUTHORIZATION
I hereby authorize the administration of medication described above to my child by School Health Program Florida licensed nurse or
by the school principal or principal’s designee (appropriately trained Marion County School System non-medical personnel.) I
hereby indemnify any and all liability of the school district, county health department, and other entities in the treatment of my
child. It is understood by the undersigned that personnel will not be responsible for possible side effects from the administration of
the above medication and may contact the physician if there are any concerns about the medication.
Parent/Guardian Signature: Date:
On the rare occasion, if I failed to provide a prescribed morning dose of medication at home, upon my verbal request, I authorize the above
designees to provide the dose. I understand that the time for the missed dose must be on the container in the school clinic.
Parent initials:
(✓ one) Possession of: Inhaler EpiPen Pancreatic Enzymes MCPS Board Policy 5.62
Florida law states a student may carry and administer a prescribed metered dose inhaler; and/or an epinephrine auto-injector (e.g.
Epipen; and/or pancreatic supplements: on his/her person while in school with approval from their parent/guardian AND their
physician. The above named child has been appropriately trained in the technique of self-administration.
Parent/Guardian Signature: Date:
Physician Signature: Date:
This form shall be maintained as part of the student’s Cumulative Health Record for a period of 7 years from stop date.
eCHN25 REV 07/2020 ~ An Equal Opportunity School District ~ C-26
AUTHORIZATION FOR PRESCRIBED MEDICATIONS
Florida Statue 1006.062
Student Name: Dosage:
Medication:
Amount Amount
Date Time Provided Given Total Left Comments Signature/Title
eCHN25 REV 07/2020 ~ An Equal Opportunity School District ~ C-26
