File: JLCD-E (pdf)
Adopted: January 8, 2019
MEDICATION ADMINISTRATION AUTHORIZATION
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
HEALTH CARE PROIVDER’S SIGNED ORDER FOR MEDICATION AT SCHOOL
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