SD167 – Administration Of Medication Form (J7)

I give permission for my child identified herein to receive the prescribed medication and/or treatment in school and/or at school-related activities and/or at school sponsored events. I agree that I am primarily responsible for administering medication to my child or ward. However, in the event that I am unable to do so or in the event of a medical emergency, I hereby authorize Brookwood School District 167 and its employees and agents, on my behalf, to administer or to attempt to administer to my child (or to allow my child to self-administer pursuant to State law, while under the supervision of the employees and agents of Brookwood School District 167), lawfully prescribed medication or treatment in the manner described herein.

I Understand That:

1. I agree to indemnify and hold harmless Brookwood School District 167 and its employees and agents against any claims, except a claim based on willful and wanton conduct, arising out of the administration to or the self-administration of medication by my child or ward.
2. Only medication authorized by a physician will be administered at school.
3. No medication, prescription, or over the counter drugs will be given to my child until all required signatures are received by Brookwood School District 167.
4. The medication dosage will not be increased, decreased or discontinued without another proper prescription.
5. Medication must be bought to the school office by the parent/guardian.
6. The school will store medication in a locked cabinet. No student will be allowed to carry his/her own medication for self-administration, except for asthma medications or epinephrine auto-injector (“EpiPen”) which a student may possess for immediate use.
7. Medications must be in its original labeling – either in its commercial packaging or in its container from a pharmacy with the original labeling.  (Duplicate containers are readily available from pharmacies for this purpose.) The container shall display the student’s name, medication name, direction for administration, dosage, prescription number if applicable, dates for administration, dosage, prescription number if applicable, dates for administration, prescriber’s name, and pharmacy contact information if applicable.
8. The responsibility for remembering to take a medication is the student’s. If this is not possible, the school will cooperate with the parent/guardian to determine a workable alternative.
9. All unused medications shall be picked up by the parent/guardian when a medication is discontinued and at the end of the school year.
10. A new “Medication Authorization Form” is required for each school year.
11. For each field trip, a written request must be submitted to the building principal for the student to receive needed medication during the field trip.