File:  JLCD-E

 

 

 

 

 

Permission for Medication

 

Name of student                                                                                              

School                                                                            Grade                       

Medication                                                                     Dosage                     

Purpose of medication                                                                                     

                                                                                                                       

Time of day medication is to be given                                                              

Possible side effects                                                                                         

                                                                                                                       

Anticipated number of days it needs to be given at school                                      

 

Date                                                                                                               

                                                          Signature of health care practitioner

 

It is understood that the medication is administered solely at the request of and as an accommodation to the undersigned parent or guardian.  In consideration of the acceptance of the request to perform this service by the school nurse or other designee employed by the _____(name of school district)_____, the undersigned parent or guardian hereby agrees to release the __(name of school district)____ and its personnel from any legal claim which they now have or may hereafter have arising out of side effects or other medical consequences of the medication.

 

I hereby give my permission for ____(name of student)____ to take the above medication at school as ordered.  I understand that it is my responsibility to furnish this medication.

 

Date                                                                                                               

                                                          Signature of parent or guardian

 

Adoption date: September 22, 2014