Boulder Valley School District


  • J
  • Students

File: JLCD-E (pdf)
Adopted: January 8, 2019


The undersigned parent(s) or guardian(s) of ______________________________________________________       hereby request personnel employed by the Boulder Valley School District RE-2 to see that said child receives
 _________________________________________      at  _______     as described by prescribing health care provider.
(name of medication)                                                             (time)

It is required by the Boulder Valley School District as a condition to its agreement to administer any medication, that the medicine has been prescribed by a health care provider and that it has been furnished by the parent(s) or guardian(s) of the student with an appropriate label stating the child’s names, name of the medicine, times at which medication is to be administered, the dosage and the date when the medication is to be stopped. It is understood that the medication is administered solely at the request of and as an accommodation to the undersigned parent(s) or guardian(s). In consideration of the acceptance of the request to perform this service by any personnel employed by the Boulder Valley School District RE-2, the undersigned parent(s) or guardian(s) hereby agree(s) to release the said institution and their personnel from any legal claim(s) which they now have or may hereafter have arising out of the administration of (or failure to administer) the medication to the student.

Dated this___________________________     day of  __________________     20___________    .

Name of Health Care Provider prescribing medication               School child attends


Signature of Parent or Guardian



Student’s Name ________________________________________    Medication ____________________________     

Route of administration _________________________    Dosage (total mg/dose)  __________________________    

to be given at  ___________________    from   ____________________    to   ____________________________    .
(time)    (date)    (date)

Purpose of medication _________________________________________________________________________      

Possible side effects ____________________________________________________________________________     

Health Care Provider’s Signature    (date)

For inhalers & EpiPens only: Provider, please sign below to give permission for student to carry and self- administer the inhaler and/or EpiPen ordered on this form.


Health Care Provider’s Signature & Date

End of File JLCD-E