High School Self-Adminstration of Medication Form
Self-Administration of Medication
by Nurse Kellie
August 11, 2005
ANDOVER PUBLIC SCHOOLS USD 385
DEPARTMENT OF HEALTH SERVICES
GRADES 9-12 MEDICATION SELF-ADMINISTRATION RELEASE FORM
I hereby certify that _________________________ has previously had at least one dose of the prescribed medication listed and did not have an adverse reaction from it. I hereby give my permission for this medication(s) to be self-administered at school as prescribed by the physician or as on the over-the-counter medication label. I understand that it is my responsibility to furnish this medication. I acknowledge that the school incurs no liability for any injury resulting from the self-administration of medication and agree to indemnify and hold the school, and its employees and agents, harmless against any claims relating to the self-administration of such medication. I hereby authorize USD #385 Department of Health Services personnel to exchange information regarding dispensing and monitoring of this medication with _______________________, the attending physician or dentist, or with the pharmacy as identified on the label of the prescribed medication container.
My child has been instructed on self-administration of the medication and is authorized to do so in school.
________________________________________________________
Signature of Parent/Legal Guardian
____________________ ________________________________
Date Telephone
NOTE: The medication is to be brought to school in the original container appropriately labeled by the pharmacy, or physician, stating the name of the medication, the dosage and times to be administered.
-------------------------------------------------------------------------------------------------------------------
Building: _________________________________Teacher/Grade____________________________
Student's Name____________________________________Birth Date:____________________
Medication:_____________________________Diagnosis:______________________________
Route:______________Dosage:________________May carry or Must keep in Nurses Office
Conditions under which the medication is to be given:___________________________________
Special Directions for Administration:_______________________________________________
_____________________________________________________________________________
Requested starting date of treatment:___________________Duration:_____________________
__________________________________________________________
Physician's Signature
_________________________ __________________________ ______________________
Telephone Fax # Date
05-06
