CHRIST THE
MEDICATION RELEASE STATEMENT
Indiana law requires that the following conditions be met when school personnel are asked to administer medication to students:
We
must have the written request of the parent/guardian on this form.
In
the case of prescription medication, the prescribing physician must provide a
written order stating the dosage, intervals, and duration for which the child
is to be medicated. (The original
prescription bottle serves this purpose).
Medication
that is brought to school must be kept in the original pharmacy container and
sent to the office immediately upon arrival to school. In cases where children have life-threatening
illnesses that require them to carry their medication at all times, we must
have a doctor’s note indicating that the child will be responsible for
possession of his/her medication (including, but not limited to asthma
inhalers).
Continuing,
long-term medication must be re-verified at the beginning of each school year.
Non-prescription medication (i.e. Tylenol, aspirin, cough drops, etc.) must also be dispensed by a school employee and will be done ONLY upon written request by the parent/guardian. The school cannot provide medication of any kind. ALL MEDICATION MUST BE PROVIDED BY THE PARENT/GUARDIAN OF THE STUDENT.
Student’s Name (Please Print) _________________________________________
I hereby give
permission for school staff members to administer medication to the above named
child during school hours in accordance with the physician’s directions
(prescription medication) or myself (over the counter medications). I agree to provide all medication in the
original container from the pharmacy and to renew long-term medication orders
at the beginning of each school year.
Name of Medication_______ ____________________________________________
Time to be
administered_________________________________________________
Date (from)___________________________________________________________
Date (to) ____________________________________________________________
Today’s Date _________________________________________________________
Parent/Guardian
Signature ______________________________________________