AUTHORIZATION FOR THE ADMINISTRATION OF MEDICINES

New Jersey law requires a physician's written order and parent/guardian authorization for administration of medicine in school.

PHYSICIAN'S ORDER

Name of Child _______________________________________________ Date _______________________________

Address _____________________________________________________ DOB _____________________________________

Condition for which drug is being administered _______________________________________________________________________

____________________________________________________________________________________________________________

Name of drug _________________________________________________________________________________________________

Time(s) of administration _________________________________________________________________________________________

Other suggestions _______________________________________________________________________________________________

_______________________________________________________

Telephone Number

_______________________________________________________

Physician's Signature

*********************************************************************************************************************

Authorization of Parent/Guardian Concerning the Administration

of Above Medicines by School Personnel

To ___________________________________________________ Date _____________________________

Name of Program

I hereby request that school personnel give my child, ___________________________________, the medication
ordered above by his physician and will not hold the Board of Education or its personnel responsible for
complications related to the medication, pursuant to P.A. 451 of 1976 -S 1178

___________________________________________________
Signature Parent/Guardian

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