Health Services Authorization to Assist in the Administration of Medication/Treatment
St. Johns County School District
Rev. 07/2026
Student Information
Student Name: [Student Name]
Date of Birth: [Date of Birth]
School: [School]
Teacher/Grade: [Teacher/Grade]
List Known Allergies: [Allergies]
Nursing Services and Medication/Treatment Order
All information must match the prescription label! All medication must be properly labeled and in original containers. Complete one form for each medication/treatment to be administered. A new form must be completed if the dosage of a medication changes at any time.
Nursing services are recommended for the care of this student during the school day. It is necessary for the following medication/treatment to be given in school and during school-sponsored activities. I am aware that non-medical personnel may administer this medication/treatment.
| Name of Medication/Treatment | Amount (Dosage) | Time to be Given | Date to Start | Date to End | Health Condition Requiring Medication | Possible Side Effects | Special Instructions | Physician Ordering Medication |
|---|---|---|---|---|---|---|---|---|
| [Medication/Treatment Name] | [Dosage] | [Time] | [Start Date] | [End Date] | [Health Condition] | [Side Effects] | [Special Instructions] | [Physician Name] |
Physician Address: [Physician Address]
Physician’s Phone: [Physician Phone]
Fax: [Fax]
Physician’s Signature: (required for all medications) [Signature]
Date: [Date]
Parent/Guardian Authorization
I authorize my child’s school nurse to assess my child regarding his/her special health care needs and to discuss these needs with my child’s physician as needed throughout the school year. I understand this is for the purpose of generating a health care plan for my child. I understand I may withdraw this authorization at any time and that this authorization must be renewed annually.
As the parent or guardian of the student named above, I request that the principal or principal’s designee assist in the administration of medication/treatment prescribed for my child.
I understand that under provisions of Florida Statute 1006.062, there shall be no liability for civil damages as a result of the administration of medication when the person administering such medication acts as an ordinarily reasonable, prudent person would have acted under the same or similar circumstances. I also grant permission for school personnel to contact the physician listed above if there are any questions or concerns about the medication. I have read the guidelines and agree to abide by them. I authorize the physician to release information about this condition to school personnel.
Parent/Guardian Signature: [Signature]
Print Name: [Print Name]
Phone Number: [Phone Number]
Date: [Date]
Emergency Medication (Inhaler/Epinephrine)
Florida law states a student may carry a metered dose inhaler or epinephrine delivery device on his/her person and self-administer while in school with approval from his/her parents and physician.
The above-named child may carry and self-administer his/her emergency medication.
Parent/Guardian Signature: (required) [Signature]
Date: [Date]
Physician’s Signature: (required) [Signature]
Date: [Date]