School Medication Authorization Form (Page 2 of 2) in pdf

For only parents/guardians of students who need to carry asthma medication or an EpiPen®:

I authorize the School District and its employees and agents, to allow my child or ward to possess and

use is or her asthma medication and/or epinephrine auto-injector: (1) while in school, (2) while at a

school-sponsored activity, (3) while under the supervision of school personnel, or (4) before or after

normal school activities, such as while in before-school or after-school care on school-operated property.

Illinois law requires the School District to inform parent(s)/guardian(s) that it, and its employees and

agents, incur no liability, except for willful and wanton conduct, as a result of any injury arising from a

student’s self-administration of medication or epinephrine auto-injector (105 ILCS 5/22-30).

If you agree, please initial:___________________________

Parent(s)/guardians(s)

For all parents/guardians:

By signing below, I agree that I am primarily responsible for administering medication to my child.

However, in the event that I am unable to do so or in the event of a medical emergency, I hereby

authorize the School District and its employees and agents, in my behalf, to administer or to attempt to

administer to my child (or to allow my child to self-administer, while under the supervision of the

employees and agents of the school District), lawfully prescribed medication in the manner described

above. I acknowledge that it may be necessary for the administration of medications to my child to

be performed by an individual other than a school nurse and specifically consent to such

practices, and

I agree to indemnify and hold harmless the School District and its employees and agents against any

claims, except a claim based on willful and wanton conduct, arising out of the administration or the child’s

self-administration of medication.

_______________________________________

________________________________________

Parent/Guardian printed name

___________________________________________

____________________________________________

Parent/Guardian signature*

Date

Parent/Guardian signature*

Date

* Both parents and/or guardians, if available, should sign.

Page 2 of 2

Revised October, 2006

7:270-E

School Medication Authorization Form Page 2