Cedar Grove School
Health Office

Medication Authorization

Parent / guardian consent to administer
Complete one form per medication. School staff cannot give any medication — even over-the-counter — without this signed authorization on file.
Student
Noah Bennett
03/14/2015
4th
Mr. Idris — Room 8
Medication to be given
Medication Dosage Time(s) at school
Albuterol inhaler
2 puffs
As needed, before PE
Amoxicillin
5 mL
12:00 PM with lunch
Oral / inhaled
May 5 – May 14, 2026
Ear infection. Give with food. Watch for rash; call parent if any appears.
Allergies & physician
Penicillin (hives) — confirmed not in this medication
Dr. Lena Okafor, Cedar Grove Pediatrics
(555) 442-1190
Aunt Mara Bennett · (555) 207-6634
Parent / guardian authorization

I authorize the Cedar Grove School Health Office to administer the medication above to my child as directed. I confirm the medication is sent in its original, labeled container, and I authorize staff to seek emergency medical care if my child cannot reach me. I will notify the school of any changes.

Andre Dubois
Parent / guardian signature
May 4, 2026
Date

For Health Office use

Tobias Lindgren
School nurse / authorized staff
May 5, 2026
Date received

Cedar Grove School Health Office · Keep medication current and labeled · Questions? Call the health office.