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

LAKE PARK HIGH SCHOOL DISTRICT 108

590 S. MEDINAH ROAD

ROSELLE, IL 60172-1978

SCHOOL MEDICATION AUTHORIZATION FORM

Student Name ______________

_____________________________Student ID____________________

Birthdate_________________Telephone Number_______________________Campus____________________

Diagnosis __________________________________________________________________________________

Medication

____Dosage

________________________

Time Given/Instructions

____Route

__Starting Date

___________

End Date

(form must be renewed each year)

Reason for medication and/or intended effect

__________________

Possible side effects

__________________

Other medications student is receiving

__________________

Emergency Phone Numbers: (list in order that numbers should be attempted)

Mother/Guardian: 1.

______

Father/Guardian: 1.

______

COMPLETE THE FOLLOWING FOR ASTHMA MEDICATION, EPI-PENS, OR INSULIN:

1. Student may carry medication on his/her person*

( ) Yes

( ) No

2. Student may self-administer medication

( ) Yes

( ) No

* We recommend that “back up” medication be stored in the office as well.

Directions for self-administration

__________________

PARENTAL AUTHORIZATION

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

authorize Lake Park High School District No. 108, and its employees and agents, on my behalf and in my stead,

to administer medication to my child or to allow my child to self-administer medication while under the

supervision of the employees and agents of the school district, lawfully prescribed medication in the manner

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

performed by an individual other than the school nurse and specifically consent to such practices. I also give

my permission for Lake Park High School District No. 108 to share all pertinent medical information about my

child with school staff members involved with my child. I further acknowledge and agree that when the

lawfully prescribed medication is so administered, I waive any claims I might have against the school district,

its employees and agents, arising out of the administration of said medication. In addition, I agree to

indemnify and hold harmless the school district, its employees and agents, either jointly or severally, from and

against any and all claims, damages, causes of action or injuries incurred or resulting from the administration

or self-administration of said medication, except a claim based on willful or wanton conduct.

________________________________________

Parent/Guardian Name (printed)

________________________________________

Parent/Guardian Signature

Date

Parent/Guardian Signature

Date

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

(over)

School Medication Authorization Form Page 2

Related Articles

Related forms

Related Categories