BRITTAN SCHOOL DISTRICT

2340 Pepper Street

Sutter, CA 95982

822-5155 FAX 822-5143

AUTHORIZATION FOR MEDICATION TO BE GIVEN AT SCHOOL

Student's Name   Birthdate  
Teacher   School Year  

Dear Parent/Care Provider:

In order for school personnel to dispense any type of medication to your child, the District is required to have an authorization on file from the child's physician and also signed by the parent/guardian of the student. (California Education Code, Section 49423).

Medication to be administered  
Dosage/How often  
Time of Day/ Duration  
Anticipated reactions to medication  

 

Medication to be administered  
Dosage/How often  
Time of Day /Duration  
Anticipated reactions to medication  

 

Additional instructions from physician  
Physician's Printed Name  
 Phone  
Physician's Signature   
Date   

I approve of this authorization for medication to be given to my child by school personnel

Parent/Care Provider  
Home Phone  
Work Phone  
 Date    

 

PARENT'S AUTHORIZATION FOR EXCHANGE OF INFORMATION

I hereby give my permission for the exchange of information regarding my child's medication between Brittan School and the following:

Physician  
Other  

 

 

 


Signature of Parent/Guardian Date

Please return to: Brittan School, FAX 822-5143

 10/02