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Authorization to Administer Medication Form

This form will be used by the health offices at Dallas Center-Grimes CSD. The completed form is sent to our nursing staff.

Dallas Center-Grimes CSD Authorization to Administer Medication

This form is used by health staff at Dallas Center-Grimes Community School District.

Name(Required)

First Last

Grade(Required)

Building(Required)

Medication(Required)

Dosage(Required)

Time to be given(Required)

Doctor's Name

Doctor's Telephone Number

Date(Required)

Parent Signature(Required)

By typing your name in the box below, you certify that you understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature