Authorization For Student To Carry Medication(Inhaler Or Epi-Pen) printable pdf download

Form B

(2 pages)

St. Joseph School

5411 South Main Street Sylvania, Ohio 43560

Authorization for Student to Carry Medication(Inhaler or Epi-Pen)

Must be read and completed by Parent/Guardian and Student

__________________________________ has been instructed in the proper use of

(name of student)

__________________________________. We request that he/she be permitted

(name of medication)

to carry the medication on his/her person or keep in his/her book bag, as we consider him/her responsible.

He/she has been instructed in and understands the purpose and appropriate method and frequency of use of

this medication. He/she also understands this medication is not to be shared or used by others. I also

understand that my child will not be monitored when using this medication nor will a specific record of its

use be kept unless he/she communicates this information to the clinic.

I authorize school personnel to allow use of this above medication to the above named child as ordered by

our health care provider. I also authorize the school nurse to consult with the health care provider about my

child’s medication needs. I will see that my child’s medication is properly labeled with the name of the

medication and my child’s name.

I understand that the student is responsible for the proper maintenance and use of the medication. I

understand that if the student is found to have shared his/her medication at school, or otherwise abused the

medication or device, the student will not be permitted to carry his/her medication at school and disciplinary

action may also occur. I understand, and have informed the student , that he/she must immediately notify the

school bus driver, school principal, school nurse, or teacher if his/her medication is lost or taken from

him/her by another person.

In consideration of the administration of medical services as requested and authorized by this form, I/we, or

myself/ourselves, and my/our heirs, executors, administrators and assigns, do hereby waive, release and

forever discharge and agree to indemnity and defend the School and Diocese of Toledo, their members,

officers, administrators, employees, servants and agents from and against all claims, demands, or causes of

action by any person or entitles, for loss, cost, injury, or damage whatsoever arising from or claimed to arise

from or in any way connected with the administration of authorized medical services to the student named

above.

As Parents/Guardians of the child named above I/We acknowledge that I/WE have read and understand the

above statements. As the student named above, I have read and understand the above information and the

responsibility I assume in keeping the above named medication on my person.

PARENT/GUARDIAN__________________________________

________________

(Signature)

(Date)

STUDENT ____________________________________________

_______________

(Signature)

(Date)

Authorization For Student To Carry Medication(Inhaler Or Epi-Pen)