Self Administration Medication Authorization Form

The Michigan Department of Education, "Model Policy and Guidelines for Administering Medications to Pupils at School" requires that parents/guardians update their child's medication forms at the beginning of every school year.  It is important to your child's well-being that these forms be completed and returned to the school office prior to the 1st day of school.

                                                    Procedure for the Delivery of Medication

Prescription Medication - All prescription medication received at the school must be in the original pharmacy-labeled container showing the dosage.

Over-the-Counter Medication - Over-the-counter medication must have the child's name clearly written on the label.  The physicians order including the dosage is required. 

If your child is old enough to carry and administer their own medication without supervision, complete the Medication Authorization Form-Physician/Parent Signature for Self-Administration/Self Possession" (Pink)

  1. The form must be completed and signed by the physician.
  2. The parent/guardian and student must sign the form.
  3. Supply your child with a copy of the form.  The student will be  expected to carry the copy on them during school hours.
  4. Return the original form to your child's school office.
  5. the student should only carry a one day supply of medication to school each day.
    - A one day supply does not apply to inhalers, and a doctor's order is still
      required for any student to carry the inhaler. 
    PDF DocumentSelf-Administration Medication Form