Parental Authorization to Administer Medicine

TO:

(Principal)                                                                           

(School)                                                                             

I am the parent with legal custody, the legal guardian, or individual assuming permanent care and custody of                                                                                                 , a student attending this school. This student requires medication at intervals during the school day. I hereby give my consent and authorize and request the school principal, or                                                                                                                                         (an employee of the school district designated by the principal, and me) to:

Administer                                                                            a non-prescription medication that I am hereby supplying you, in accordance with the written instructions of the child's physician that is attached hereto.

Administer                                                                            , a filled prescription medication that I am hereby supplying you, in accordance with the directions for the administration of the medicine listed on the label of the vial.

Administer                                                                            , a filled prescription medication that I am hereby supplying you, in accordance with the written instructions ofthe physician prescribing the medicine, which is attached hereto.

Permit the student to retain the medication on the student's person since the medication must be administered at unpredictable intervals throughout the day. A physician's statement that the student is capable of, and has been instructed in the proper method of, self-administration of medication is attached.

I understand that under state law, the board of education, the school district, or the employees of the district shall not be liable to the student or the student's parent or guardian for civil damages for any personal injuries to the student which result from acts or omissions of school employees in administering the medicine I have hereby authorized or from the self-administration of medication by the student.

Dated this                 day of