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Jefferson County Public Schools (JCPS)

2012-2013

Authorization to Give Over the Counter Medication

(This Form Requires a Healthcare Provider’s Signature)

Student: ____________________________________________ Date of Birth: ___________________

School: ____________________________________________ School Year: ___________________

I hereby request Jefferson County Public Schools personnel to give the above named student medication

that has been prescribed by ________________________(Print Provider Name)

________________________ (Provider’s Signature).

***

Health care provider’s telephone no.: _______________________ Fax no. ____________________________

Health care provider’s address: _________________________________________________________

Date of last office visit: _________________

Date to start medication: _________________________ Date to stop medication: ________________

Reason medication is needed: __________________________________________________________

Reactions/side effects: ________________________________________________________________

Instructions for giving my child this medication:

1. Name of medication: ______________________________________________________________

2. Dosage to be given: ______________________________________________________________

3. Time of day for dosage: ____________________________________________________________

4. Route of administration (e.g., mouth, nose, eyes, ears):____________________________________

5. Special instructions (e.g., take on empty stomach): _______________________________________

Note: Health Care Provider must sign and signature of parent/guardian must be notarized.

*************************************************************************************************

****

I hereby acknowledge that if this medication is not self-administered, it will most likely be administered by trained,

unlicensed JCPS personnel. I acknowledge and agree when I authorize my child to attend a school sponsored field trip

this medication may also be administered by a licensed volunteer. By signing this form, the parent/guardian

acknowledges that the Jefferson County Board of Education, its employees and agents shall incur no liability as a result of

any injury sustained by the student from any reaction to any medication, unless the injury is the result of negligence or

misconduct on behalf of the school or its employees. The parent/guardian shall hold harmless the school and its

employees against any claims made for any reaction to any medication or the administration of such medication unless

the reaction is due to negligence or misconduct on behalf of the school or its employees. Also, I hereby give permission

for the health care provider completing and signing this form to verify this information with JCPS and to consult with

JCPS staff regarding this information.

_____________________________

_____________

___________________

Printed Name of Parent/Guardian

Telephone

Cell Phone

____________________________

____________________

_____________________

Signature of Parent/Guardian

Father/Guardian (Work)

Mother/Guardian (Work)

Emergency Contact_______________________

Relationship______________________

Telephone_______________________

Notary Section: Subscribed and sworn to before me this ________ day of ____________, 20_______

______________________________________________, Jefferson County, KY _______________________________

Signature, Notary Public

Date Commission Expires

Final 1/13/12

Authorization To Give Over The Counter Medication Form - Jefferson County Public Schools - 2012-2013 Page 2

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