Student Medication Or Medical Treatment - Westmount Charter School Page 2
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2Medication/Treatment Information (cont.)
Possible side effects of medication(s)/treatment and remedial action for side effects:____________________________________
_______________________________________________________________________________________________________
Will it be detrimental to the student’s health if a single dose/treatment is omitted?
Yes___
No___
Must this student have this medication/treatment administered during school hours in order to be able
to attend school?
Yes___
No___
Self-Administration Information
Is this student able to administer his/her own medication/treatment?
Yes___
No___
If yes, provide details: ____________________________________________________________________________________
______________________________________________________________________________________________________
Charter Board policy requires that, except in emergencies, the student shall self-administer under adult supervision.
Informed Parental Consent and Acknowledgement
I am the parent of the student named above (“my child”) and I acknowledge and agree:
1. I will provide an adequate and fresh supply of medication for my child.
2. I understand the medication will be stored in a secure location and administered by school staff unless I have given consent
for my child to self-administer the medication.
3. I understand it is my responsibility to advise school staff of any change in my child’s medical condition or medication.
4. I acknowledge that actions taken by school personnel will be limited to what is possible in a school setting, and to what can be
done by persons untrained in medical procedures.
5. If any emergency arises, I authorize school personnel to administer medication and/or secure medical advice and services,
including calling paramedics as deemed necessary. I agree to be financially responsible for such emergency medical
assistance.
6. By signing this form, I consent to and authorize school personnel to administer medication/medical treatment to my child.
7. I understand that the Charter Board fully accepts responsibility for students under its care, and is liable to the parents and the
students for any loss, injury or damages which occur as a result of the negligence of the school. I am fully aware that there
are risks and hazards associated with the administration of medication or medical treatment and that my child may suffer
bodily injury as a result of these risks and hazards, and my child may suffer personal and potentially serious injury due to an
unforeseeable or fortuitous event.
8. This form is valid only for the school year in which it is submitted.
Date: _____________
Name of Parent: __________________________
Signature: ________________________________
Physician’s Endorsement
1. The information provided on this form is accurate and complete.
2. The assistance of school personnel required to administer this medication and/or medical treatment is within the competence
of persons untrained in medical procedures.
Date: _____________
Name of Physician: _______________________
Signature: _______________________________
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