Permission to Self Carry Medication Form "2"
by Katie Kettler
January 15, 2007
USD # 415
PERMISSION FOR SELF-ADMINISTRATION OF MEDICATION
Name of Student ______________________________________________
School ________________________________________ Grade ____________
Teacher (s) ______________________________________________________
Medication __________________________________ Dosage ______________
Date Started ______________________________________________________
Conditions under which the medication can be taken:
________________________________________________________________
Length of time medication is to be administered:
________________________________________________________________
I hereby give my permission for _________________________ to administer the above medication at school as ordered. I understand that it is my responsibility to furnish this medication. I acknowledge that the school incurs to liability for any injury resulting from the self-administration of medication and agree to indemnify and hold the school, and its employees and agents, harmless against any claims relating to the self-administration of such medication.
**My child has been instructed on self-administration of the medication and it authorized to do so in school.**
Signature Parent/Guardian: ______________________________ Date _____________
Signature of Health Care Provider: ________________________ Date ______________
Approved:
