Glenbard Township High School District 87
Policy 7:270-E1
Students
Exhibit – School Medication Authorization Form
Front of form to be completed by the child’s parent(s)/guardian(s) and kept in the school nurse’s office or, in the absence of a school nurse, the Building Principal’s office: Back of form to be completed by physician.
Student’s Name: |
Birth Date: |
Address: |
Home Phone: |
Emergency Phone: |
School: |
Grade: Student I.D.: |
For parent(s)/guardian(s) of students who have asthma:
I authorize the School District and its employees and agents, to allow my child or ward to possess and use his or her asthma medication (1) while in school, (2) while at a school-sponsored activity, (3) while under the supervision of school personnel, or (4) before or after normal school activities, such as while in before-school or after-school care on school-operated property.
Illinois law requires the School District to inform parent(s)/guardian(s) that it, and its employees and agents, incur no liability, except for willful and wanton conduct, as a result of any injury arising from a student’s selfadministration of medication (105 ILCS 5/22-30). _____________________ If you agree please initial: Parent(s)/Guardian(s) Initial |
By signing below, I agree:
1. That I am primarily responsible for administering medication to my child. However, in the event
that I am unable to do so or in the event of a medical emergency, I hereby authorize the School
District and its employees and agents, in my behalf and stead, to administer or to attempt to
administer to my child (or to allow my child to self-administer, while under the supervision of the
employees and agents of the School District), lawfully prescribed medication in the manner
described above. I acknowledge that it may be necessary for the administration of
medications to my child to be performed by an individual other than a school nurse, and
specifically consent to such practices, and
2. To indemnify and hold harmless the school district and its employees and agents against any
claims, except a claim based on willful and wanton conduct, arising out of the self-administration
of medication by the pupil.
________________________________________ ____________________________________
Parent/Guardian’s Signature Date Parent/Guardian’s Signature Date
To be completed by the student’s physician:
Physician’s Printed Name:
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Office Address:
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Office Phone:
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Emergency Phone: |
Medication:
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Dosage:
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Frequency: |
Time medication is to be administered or under what circumstances:
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Diagnosis requiring medication:
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Intended effect of this medication:
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Must this medication be administered during the school day in order to allow the child to attend school or to address the student’s medical condition? Yes No
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Expected side effects, if any:
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Other medications student is receiving:
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______________________________________________________________
Physician’s Signature Date
DATED: May 1999
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