REQUEST TO ADMINISTER MEDICATION AND RELEASE AGREEMENT

SPEARFISH SCHOOL DISTRICT 40-2

 

I hereby request and give my permission to the Spearfish School District 40-2 to administer medication to the student identified below. I understand that it is my responsibility to provide this medication.

 

NAME OF STUDENT_______________________________________________________                                         BIRTHDATE__________________________________

 

SCHOOL_________________________________                        GRADE_______                            TEACHER____________________________________

 

NAME OF PHYSICIAN______________________________                                                             TELEPHONE___________________________________

 

MEDICATION____________________________                    PURPOSE__________________________________________                  DOSAGE_________________-

 

TIME TO BE GIVEN__________________________________________                                     POSSIBLE SIDE EFFECTS_______________________________________

 

PERIOD OF TIME FOR CONTINUATION OF MEDICATION- FROM_______________________ TO___________________________

 

I understand that all medication must be provided in the original pharamcy labeled containers. I understand that my child assumes reponsibility for going to the school secretary at the SPECIFIED TIME (S) FOR MEDICATIONS. It is the parent (s) or parent's adult designee's responsibility to transport all medications to the office.

I acknowledge that the adminsitration of this medication by school personnel is an accomodation performed solely upon my rewuest. In consideration of the acceptance of this request, I release and waive any and all claims which I now have or may hereafter have against the Spearfish School District 40-2 and its employees arising out of teh administration of or failure to administer the medication to the student or adverse reaction by the student to the medication.

 

___________________________________________________________                                     _______________
Parent or Legal Guardian                                                                                               Date

 

 

 

 

 

 

MEDICATION ADMINISRATION FORM

NAME OF STUDENT________________________________________________________________  (Note time and initial)

	Week of:	Mon	Tue	Wed	Thurs	Fri	Week of :	Mon	Tues	Wed	Thurs	Fri.
Medication_________________ Dosage____________________ Time to be adm_____________
Medication_________________ Dosage____________________ Time to be adm_____________
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Medication_________________ Dosage____________________ Time to be adm_____________
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Medication_________________ Dosage____________________ Time to be adm_____________