Permission to Self Carry Medication Form "2"

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: