Parent Authorization for Administration of Medication

I or We, the undersigned parent or guardian of the student named below, hereby authorize without condition the Rockingham County Public Schools and its employees to allow this student to take for legitimate medicinal treatment of a present medical condition the following described substance. I or We acknowledge that we have reviewed with this student and understand the Substance Abuse Policy of the Rockingham County School Board and that any violation of it may result in the suspension or expulsion of a student. I or We certify that all of the information contained in this authorization is correct and represent to the Rockingham School Board that its employees may rely upon this authorization until it is withdrawn in writing. I or We release the Rockingham County School Board and its employees from any claim or liability in any way connected with the reliance on this authorization, and we promise to indemnify, defend, and hold harmless the Rockingham County School Board and its employees from any claim or liability in any way connected with reliance on this authority.

I request that the following medication be given to my child during the school day:

Name of student:_________________________________________________________

Name of Parent or Guardian:________________________________________________

Phone Number (home):___________________________ (Work)___________________

Nature of present medical condition requiring medication:_________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Name of medication used to treat medical condition:

Prescription: _______________________________________________________

Prescribing Physician: _______________________________________________

Non-Prescription: ___________________________________________________

Dosage needed during school day: ___________________________________________

Time medication is to be taken at school: _______________________________________________________________________

Beginning Date: _____________________________ Ending Date: _________________

____________________ _____________________________

Date Parent or Guardian signature

*Prescription drugs may be administered by school personnel only with the prior written permission of the parents, and the physician (permission implicit in the original pharmaceutical package), stating the type, dosage, and duration of treatment.