District of Columbia Medication and Treatment Authorization Form
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GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF HEALTH
School Health Program
AUTHORIZATION FOR MEDICATION ADMINISTRATION FORM
NAME OF STUDENT: __________________________________________________ DOB: ______________________________
SCHOOL: _____________________________________ SOC. SEC. #_________________ Grade: ____________________
PARENT/GUARDIAN CONSENT FORM
Please complete and sign this action.
I hereby request and authorize the School Nurse/Licensed Practical Nurse/Trained Certified DCPS Personnel to
administer prescribed medication as directed by the physician to ___________________________________________.
I have read the procedures on the reverse side of this form and agree to assume the responsibilities as required.
This medication is a
new or renewal prescription. If new prescription, enter date and time the first dose
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