Brookfieldacademy.org

MEDICATION ADMINISTRATION AUTHORIZATION (MAA)
This form due by Thursday, July 29, 2010
Please refer to the Administering Medications Policy for guidelines in completing this form. No medication will
be given until the school receives this completed form with the prescribed medication in a container
appropriately labeled by the pharmacy and/or physician.
A fax to 262-783-3216 Attn: School Nurse, is acceptable.
Student Name:
Address: City:
Home Phone:
Over-the-counter Medications [including Acetaminophen (Tylenol) and Ibuprofen (Motrin)]

Medication Name: _______________________________________ Dosage: ____________________
Route: __________________________________ Frequency/Time: ______________________________
Physician Section
Medication Name:
Frequency/Time:
Stop Date:
Reason medication prescribed:
What (if any) reactions or side effects can be expected?
If medication not given regularly, what symptoms must be present prior to administration?

Name of physician prescribing medication:
Physician’s
(For inhaler use only):
I have instructed _______________________ in the proper way to use inhaled asthma medication.
It is my professional opinion that he/she be allowed to carry and use this
asthma medication by him/herself.
It is my professional opinion that he/she NOT be allowed to carry and use this
asthma medication by him/herself.
Physician Signature: Date:
(Required for all prescriptions including inhaler use)
Parent/Legal Guardian Authorization
1. I hereby give permission for the above medications to be given during school hours as ordered by my
child’s health care provider. I also request the medication(s) be given on field trips, as prescribed.
2. I hereby give permission for OTC stock Acetaminophen (Tylenol) and/or Ibuprofen (Motrin) to be
given, as designated on the Emergency Form for the current school year.
3. I give permission for the school nurse to communicate, as needed, with Brookfield Academy staff
concerning my child’s health condition(s) and the action of the medication(s).
4. I give permission for the school nurse to consult with my child’s licensed health care provider
concerning any questions regarding the listed medication(s) or medical conditions(s) being treated by
the medication(s).
5. I give permission for the medication(s) to be given by designated personnel as delegated by the
School Nurse or Head of School.
_________________________________________ ____________ _________________________
Parent/Guardian Signature Date Relationship to Student

Source: http://brookfieldacademy.org/media/18682/student%20medication%20administration%20authorization%20form.pdf