PERMISSION FOR ADMINISTERING MEDICATIONS IN SCHOOL

I hereby request that the Cottonwood Valley Charter School cooperate with the prescribing physician and assist with the administration of medication pursuant to the Cottonwood Valley School. Recognizing that the Cottonwood Valley Charter School is under no obligation to administer such medication, I hereby waive any claim for injury against the Cottonwood Valley Charter School, or its employees arising from the administration of such medication.  

Student's Name_____________________________________________ DOB: ______________

School________________________________________________________________________

Parent's/Guardian's Name______________________________________________________

Address____________________________________________________________________

Phone Number____________________________________

TO BE COMPLETED BY PHYSICAN

Medical condition which necessitates medications:

Name of Medicine(s):

Directions for medications:

Options for administration (check one or more):

• Self-administration (unsupervised)

• Self-administration (supervised)

• Administration by nurse or authorized personnel

Physician's Signature    ______________________________________________________ Date  _______________________

TO BE COMPLETED BY PARENT /GUARDIAN:

The medication listed above must be taken during school hours as directed by the physician. I grant permission for the Cottonwood Valley Charter School to exchange information with my child's doctor as deemed necessary.

I hereby request that the Cottonwood Valley Charter School cooperate with the prescribing physician and assist with the administration of medication pursuant to the instructions above.

Recognizing that the Cottonwood Valley Charter School is under no obligation to administer such medication, I hereby waive any claim for injury against the Cottonwood Valley Charter School, or its employees, arising from the administration of such medication.

Furthermore, I agree to indemnify Cottonwood Valley Charter School and its agents and employees against any claims, suits, judgments, or costs of defense (including attorneys' fees). Arising from the administration of such medication.

___________________________________________     ___________________

Parent's/Guardian's Signature                                          Date

___________________________________________    ___________________

School Administrator's Signature                                    Date