Knoxville School District 202



Knoxville School District 202School Medication Authorization FormPrescription MedicationsFax: 309-289-9300To be completed by Prescriber’s office & Parent: This form is valid for one school year. Date__________ School Year: 2019-20 Date of Birth: ____________ Grade:_____I hereby give permission for my child, __________________________________, to have the following medication administered by the school nurse or designated school personnel during the school day:Medication:_________________________________Dose:_________________Time to be given:_______________________Date to begin:________________ Date to end:__________________Reason to give medicine:______________________________________**PRESCRIBER signature required for ALL PRESCRIPTION medicationsSigned: _______________________________________Date:__________ Parents of Children who self-carry Inhalers and Epipens: I authorize the school district and its employees to allow my child to possess and use his/her inhaler and/or Epipens during all school hours and any off-hour school activities. Illinois Law requires the school district to inform parents, guardians that its employees incur no liability, except for willful and wanton conduct, as a result of any injury arising from a student’s self-administration of medication (Public Act 096-1460) Parents Please Initial________Medication policy reminders:? All prescription medications must have a physician’s and parent’s signature.? All medications administered at school must be checked in at the nurse’s office with required authorization. Medication must be received in its original container and must be labeled with the student’s name. This authorization is valid for the school year named above and must be renewed each year.By signing below I agree that I am primarily responsible for administrating medicine to my child. However in the event I am unable to do so or in a medical emergency, I hereby authorize Knoxville School District and its employees, in my behalf and stead, to administer 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 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. This medication authorization form is valid for one school year only and will need to be renewed each new school year. Any medications left at the school at the end of the school year will be disposed of in a proper manner.________________________________________________________________________________________________PARENT/ GUARDIAN PRINTED NAME PARENT/ GUARDIAN SIGNATURE DATEEmergency Phone #:___________________ Secondary phone #:______________________ ................
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