Policy JLCD-E Permission for Medication

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 Huerfano School District Re-1, the undersigned parent or guardian hereby agrees to release the Huerfano School District Re-1 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

Issued: August 9, 2010

Revised: October 11, 2005

Revised: October 26, 2010

Revised: September 23, 2014

Huerfano School District Re-1, Walsenburg, Colorado