The Carthage R-9 School District Self-Administration of Medication Permission Form allows students to carry, self-administer, or have supervised self-administration of emergency medication during school or school activities. The form must be completed and signed annually by the physician, parent/guardian, and student (if applicable). The school district is not liable for any injuries arising from student self-administration of medication according to this form.
The Carthage R-9 School District Self-Administration of Medication Permission Form allows students to carry, self-administer, or have supervised self-administration of emergency medication during school or school activities. The form must be completed and signed annually by the physician, parent/guardian, and student (if applicable). The school district is not liable for any injuries arising from student self-administration of medication according to this form.
The Carthage R-9 School District Self-Administration of Medication Permission Form allows students to carry, self-administer, or have supervised self-administration of emergency medication during school or school activities. The form must be completed and signed annually by the physician, parent/guardian, and student (if applicable). The school district is not liable for any injuries arising from student self-administration of medication according to this form.
The Carthage R-9 School District Self-Administration of Medication Permission Form allows students to carry, self-administer, or have supervised self-administration of emergency medication during school or school activities. The form must be completed and signed annually by the physician, parent/guardian, and student (if applicable). The school district is not liable for any injuries arising from student self-administration of medication according to this form.
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Carthage R-9 School District
Self-Administration of Medication Permission Form
To Carry, Self-Administer or have Supervised Self-Administration
If it is necessary for your child to carry, self-administer or have supervised self-administration of his/her own emergency medication during the school day, on school property, on the school bus, and at school activities, the following form needs to be completed and returned to the school nurse as soon as possible. The Physician, Parent/Guardian, and Student (if applicable) MUST sign this form annually.
The Carthage R-9 School District and its employees or agents shall not be held liable as a result of injury arising from the self-administration of medication by this student.
Student_____________________________ DOB ____________ School_________________ Grade____
Medical diagnosis/history: _______________ Name of physician _______________ fax ___________
I have determined that it is necessary for this medication to be self-administered or supervised self-administered by this student during school hours. This student is capable of and has been instructed in the proper method of self-administering this medication, and has been informed of the potential for harm if others are permitted to use this students medication.
____________________________________________________________ ___________________ Physician (or licensed prescriber) signature Date
As Parent/Guardian, I authorize Carthage R-9 School District to allow the above named student to self-administer or have supervised self-administration of this medication. I acknowledge that the Carthage R-9 School District and its employees or agents shall incur no liability arising from the students self-administration or supervised self-administration of this medication. I also acknowledge the potential for other students to possibly interfere with his/her medication administration outside the controlled parameters of the school office and adult supervision.
___________________________________________________________ __________________ Parent/Guardian signature Date
I have been instructed by my Physician and will be responsible for the proper method of self-administering the above named medication. I will not permit others to use this medication, realizing the potential harm to them in doing so.
___________________________________________________________ __________________ Student signature (only if going to carry and self-administer without supervision) Date
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