Permission for Medication
Name of student
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
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.
Signature of parent or guardian
Adoption date: September 22, 2014