Scheduled And "As Needed" (Prn) Medication Permission Form (Page 2 of 2) in pdf

Scheduled and As-Needed “PRN” Medication Permission

Related signs and symptoms of condition which constitute a medical emergency for which EMS and parent

called:

Maximum number of treatments per school day not to exceed

Additional instructions/comments

Supplies needed

Amount

Skills required to administer treatment/medication:

Method of administration of treatment/medication:

Additional instructions/comments:

This medication may/may not be carried by school personnel to school-related events or off-campus events.

Beginning Date:

End Date:

SIGNATURE OF PHYSICIAN: _________________________________________________ DATE: ___________________

(STAMPED SIGNATURE NOT ACCEPTED)

PRINTED NAME: _______________________________________________________________________________________

PHYSICIAN’S TELEPHONE NUMBER: ___________________________________________________________________

Parent or Guardian

I want to be called:

___Before giving the medication

___After medication is given

___Other

Comments or information:

I hereby request that the medication specified above is given to the above named student and that someone gives

the medication other than a medically trained person.

I realize that the school does not have to agree to allow medication to be given to a student by school personnel. I

understand that the school’s agreeing to allow the medication to be given is for my benefit and the student’s benefit.

Such agreement by the school is adequate consideration of my agreements contained herein. In consideration for

the school agreeing to allow the medication to be given to the student as requested herein, I agree to indemnify and

hold harmless the Archdiocese of Galveston – Houston, its servants, agents, and employees including, but not limited

to the parish, the school, the principal, and the individuals giving the medication of and from any and all claims,

demands, or causes of action arising out of or in any way connected with the giving of the medication or failing to give

the medication to the student. Further, for said consideration, I, on behalf of myself and the other parent of the

student, hereby release and waive any and all claims, demands, or causes of action against the Archdiocese of

Galveston – Houston, its agents, servants, or employees, including, but not limited to the parish, the school, the

principal, and the individual giving or failing to give the medication.

SIGNATURE OF PARENT/ GUARDIAN: ________________________________________ DATE: ___________________

July 2008

Scheduled And "As Needed" (Prn) Medication Permission Form Page 2