Medication Authorization

If you don’t want to submit the form online you can click the link below to download the file and submit to our school.
Medication Authorization

For Prescription and Non-prescription Medications VDSS Division of Licensing Programs Model Form INSTRUCTIONS:
1. Section A must be completed by the parent/guardian for ALL medication authorizations.
2. Section A and Section B must be completed for any long-term medication authorizations (those lasting longer than 10 working days). In order to submit section B, you must download the form and take it to your physician to be signed.

Section A: To be completed by parent/guardian

Medication Authorization

Medication authorization for:*

CRCS trained staff members have permission to administer the following medication

I agree and provide permission to administer the following medication

Check here to indicate agreement

Email*

Medication Name*

Dosage and times to be administered.*

Special instruction (if any)

This authorization is effective from:*

This signed form is valid for 10 school days from the submission date

This authorization is effective until:*

*

I, the parent have full knowledge on the matters said above

If you are human, leave this field blank.

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