Midland Community Unit School District No

MIDLAND COMMUNITY UNIT SCHOOL DISTRICT NO. 7

SCHOOL MEDICATIONS AUTHORIZATION FORM

Student's Name______Birthdate______

Address______Home Phone______

School______Grade______Teacher______

Emergency Phone No.______

To be completed by student's physician:

Name of Medication______

Dosage______Frequency______Time to be given in school______

Date of prescription______Date of order______

Discontinuation date______

Diagnosis requiring medication______

Intended effect of this medication______

Must this medication be administered during the school day in order to allow the child to attend school or to address the student's medical condition?______

Expected side effects, if any______

Time interval for re-evaluation______

Other medications student is receiving______

Physician's name-signature______

Physician's name-print______

Address______

Date______Office Phone______Emergency Phone______

What brand of aspirin, Tylenol or substitute does your child take and dosage. If your child takes this medication on a regular basis you will be asked to send a regular supply otherwise medication can be received in the office on a temporary basis.

______Brand ______Dosage MIDLAND COMMUNITY UNIT SCHOOL DISTRICT NO. 7

STUDENT MEDICATION AUTHORIZATION

______confirm that I am primarily responsible for administering medication to my child. However, in the event that I am unable to do so or in the event of a medical emergency, I herby authorize Midland High School District and it's employees and agents, in my behalf and stead, to administer or to attempt to administer to my child (or allow my child to self-administer, while under the supervision of the employees and agents of the school district), lawfully prescribed medication in the manner listed above. I ACKNOWLEDGE THAT IT MAY BE NECESSARY FOR THE ADMINISTRATION OF MEDICATIONS TO MY CHILD TO BE PERFOMED BY AN INDIVIDUAL OTHER THAN A SCHOOL NURSE, AND SPECIFICALLY CONSENT TO THOSE PRACTICES. I further acknowledge and agree that, when the lawfully prescribed is so administered or attempted to be administered, I waive any claims I might have against the school district, its employees and agents arising out of the administration of said medication. In addition, I agree to hold harmless and indemnify the school district, its employees and its agents, either jointly or severally, from and against all claims, damages causes of action or injuries incurred or resulting from the administration or attempts at administration of said medication.

______Parent's Signature Date