Garfield Re-2 Policies

JLCD-E 1

GARFIELD SCHOOL DISTRICT NO. Re-2

 

Permission for Medication

 

Name of student:_______________________________________________

 

School:_________________________________________Grade:_________

 

Please check one:

 

(  )  Student to carry (self-administer) medication with him/her.  Only one day’s supply of medicine is to be carried by the student.  An asthma inhaler and insulin are the only exceptions to this requirement.

 

(  )  Medication is to be kept and given in the health room.

 

Medication:____________________________Dosage:____________________

 

Purpose of medication:______________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Time of day medication is to be given:__________________________________

 

Possible side effects:_______________________________________________

 

________________________________________________________________

 

Anticipated number of days it needs to be given at school:__________________

 

________________________________________________________________

 

Date:________________      _________________________________________

                      Signature of Health Care Practitioner

 

It is understood that the medication is administered solely at the request of and as an accommodation to the undersigned parent or guardian.  In consideration of the acceptance of the request to perform this service by the school nurse or other designee employed by the Garfield Re-2 School District, the undersigned parent or guardian hereby agrees to release the Garfield Re-2 School District and its personnel from any legal claim which they now have or may hereafter have arising out of side effects or other medical consequences of the medication.

 

I hereby give my permission for_______________________________________

to take the above medication at school as ordered.  I understand that it is my responsibility to furnish this medication. 

 

A new Permission for Medication form must be completed for each medication change and each school year.

 

______________________________________  Date:______________ 

Signature of Parent or Guardian

 

______________________________________  

Parent/Guardian's printed name  

 

Note:   In the case of prescription medication, it is to be brought to school in a container appropriately labeled by the pharmacy or health care practitioner, stating the name of the medication and the dosage.

 

Approved: November 26, 1996

Recoded: November 27, 2007

Revised: September 28, 2010

 

Garfield School District No. Re-2, Rifle, Colorado