File: JHCD-F

ROCKINGHAM COUNTY PUBLIC SCHOOLS

Parent Authorization for Administration of Medication

I/We, the undersigned parent or guardian of the below-named student, 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/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/We certify that all of the information contained in this authorization is correct and represent to the Rockingham County School Board that its employees may rely upon this authorization until it is withdrawn in writing. I/We release the Rockingham County School Board and its employees from any claim or liability in any way connected with 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/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/Guardian

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.

7/01 RCPS ROCKINGHAM COUNTY SCHOOL BOARD