504.32-E Parent/Guardian Authorization and Release Form for the Administration of Voluntary School Supply of Stock Medication for Life-Threatening Incidents

Click here to download the form

Student Name: ______________________
Student Birthdate: ___________________
Building: __________________________
Date: _____________________________

The district seeks to provide a safe environment for students, staff, and visitors who are at risk of potentially life-threatening incidents. The district supplies the following prescription medications for life-threatening incidents that are listed below. Generic brands may be substituted. (Select all that apply)

            _____ Epinephrine Delivery Systems

            _____ Opioid Antagonists

Pursuant to state law, the district or its employees are to incur no liability for any injury arising from the provision, administration, failure to administer, or assistance in the administration of the selected prescription medications supplied by the district for life-threatening incidents provided they have acted reasonably and in good faith.

The parent or guardian shall sign consent for the student to receive the voluntary school supply of stock medications listed for life-threatening incidents and sign a statement acknowledging that the district is to incur no liability as a result of administration of a prescription medication for life-threatening incidents provided the district to have acted reasonably and in good faith. Electronic signatures meet the requirement of written signatures.

  • I request the above-named student be administered the voluntary stock supply of prescription medication, in the name of the district, by a school nurse or personnel trained and authorized to administer to a student who, acting reasonably and in good faith, perceives the student may be experiencing symptoms associated with a life-threatening incident following the administration instructions listed as identified in the required annual awareness training associated with the stock medication(s) above and after completion of the medication administration course requirements.
  • I understand the district and its employees acting reasonably and in good faith shall incur no liability as a result of administration of the prescription medication(s) for life-threatening incidents provided the district to have acted reasonably and in good faith.

Parent/Guardian Signature:  ___________________________
                                                              (Agreed to above statements)
Date: ___________________
                                                  

Adopted: 10/23
Revised: 9/26
Related Policy: 504.32
IASB Reference: 804.5-E(1)