Severn School Prescription Medication Administration ...
Severn School Prescription Medication Administration Authorization _____________________________________________ ____________
STUDENT NAME
____________________________________________
SCHOOL YEAR MEDICATION NAME
A. General Acknowledgement and Waiver By executing this provision, I/we hereby affirm and acknowledge that I/we have been informed as to the risks associated with the above named student’s use of the above named medication and I/we, on behalf of myself/ourselves, my/our child, and all of my/our personal representatives hereby agree to defend, hold harmless, indemnify, release and forever discharge Severn School, its agents and its employees from and against any and all claims, demands, and actions or causes of actions on account of any damage to personal property, personal injury or death which may result from the administration of the medication indicated above to the above named student. Furthermore, I/we recognize and affirm that the above named mediation has been duly prescribed by an appropriate and licensed individual/entity and I/we acknowledge that Severn School bears no responsibility and/or liability for any potential misdiagnosis made by a prescribing individual/entity not employed by Severn School in connection with the medication indicated above and/or any error made in the filling of the above indicated medication’s prescription order by any individual/ entity not employed by Severn School. Furthermore, I/we understand and acknowledge that the School Nurse will call the prescriber, as allowed by HIPAA and;/or any other applicable State and/or Federal regulations, and I/we hereby authorize the School Nurse to communicate with any health care provider as allowed by HIPAA and/or any other applicable State and/or Federal regulations. ____________________________________________________ _____________
PARENT / GUARDIAN / ADULT STUDENT SIGNATURE
B.
DATE
______________________________
______________________________
______________________________
HOME PHONE
CELL PHONE
WORK PHONE
Acknowledgement and Waiver as to Student Self-Administration and Self-Carrying of Medication By executing this provision, I/we hereby affirm and acknowledge that I/we am/are aware of the risks associated with the above named student’s self -administration and/or self-carrying of the above named medication and being so educated do hereby on behalf of myself/ourselves, my/our child, and all of my/our personal representatives knowingly agree to defend, hold harmless, indemnify, release and forever discharge Severn School, its agents and its employees from and against any and all claims, demands, and actions or causes of actions of any sort on account of damage done to personal property, personal injury or death which may occur as a result of his/her self administration and/or self-carrying of the medication named above and/or as a result of his/her failure to self-carry and/or self-administer the above named medication in the event that he/she has been authorized to self-carry and/or self-administer same. ____________________________________________________ _____________
PARENT / GUARDIAN / ADULT STUDENT SIGNATURE
C.
DATE
______________________________
______________________________
______________________________
HOME PHONE
CELL PHONE
WORK PHONE
Severn School Policy on Administration of Medication By executing this provision, I/we am/are agreeing to the following terms and conditions: a) The parent/guardian shall give the student named above (or if the student is over eighteen years he/she will give himself/herself) the first dose of any new prescription or over-the-counter medication, except for pro re nala (PRN)/emergency medication (e.g. Epi-Pen); b) The determination as to whether a student may self-carry and/or self-administer medication shall be vested with the student's parent(s)/guardian (s) (or the student himself/herself if over the age of eighteen years) and Severn School shall assume no responsibility and/or liability which may arise as a result of the parent(s)’/guardian(s)’/adult student's decision. However, Severn School by and through its agents and/or employees explicitly reserves the right to reject said parent(s)’/guardian(s)’/adult student's determination if in the discretion of Severn School a particular student's self-carrying or self-administration of a medication would be inappropriate. c) If the medication named above is a narcotic and/or scheduled, then the parent/guardian of the above named student (or the student himself/ herself if he/she is over the age of eighteen years) shall personally bring the medication directly to the school nurse and shall provide the school nurse with no more than a thirty (30) day supply of same. I/we shall be responsible for executing a new order and authorization every thirty (30) days for the administration of any non-PRN narcotic which must be administered for any period exceeding thirty (3) days. ____________________________________________________ _____________
PARENT / GUARDIAN / ADULT STUDENT SIGNATURE
DATE
______________________________
______________________________
______________________________
HOME PHONE
CELL PHONE
WORK PHONE
STUDENT NAME
____________________________________________
SCHOOL YEAR MEDICATION NAME
A. General Acknowledgement and Waiver By executing this provision, I/we hereby affirm and acknowledge that I/we have been informed as to the risks associated with the above named student’s use of the above named medication and I/we, on behalf of myself/ourselves, my/our child, and all of my/our personal representatives hereby agree to defend, hold harmless, indemnify, release and forever discharge Severn School, its agents and its employees from and against any and all claims, demands, and actions or causes of actions on account of any damage to personal property, personal injury or death which may result from the administration of the medication indicated above to the above named student. Furthermore, I/we recognize and affirm that the above named mediation has been duly prescribed by an appropriate and licensed individual/entity and I/we acknowledge that Severn School bears no responsibility and/or liability for any potential misdiagnosis made by a prescribing individual/entity not employed by Severn School in connection with the medication indicated above and/or any error made in the filling of the above indicated medication’s prescription order by any individual/ entity not employed by Severn School. Furthermore, I/we understand and acknowledge that the School Nurse will call the prescriber, as allowed by HIPAA and;/or any other applicable State and/or Federal regulations, and I/we hereby authorize the School Nurse to communicate with any health care provider as allowed by HIPAA and/or any other applicable State and/or Federal regulations. ____________________________________________________ _____________
PARENT / GUARDIAN / ADULT STUDENT SIGNATURE
B.
DATE
______________________________
______________________________
______________________________
HOME PHONE
CELL PHONE
WORK PHONE
Acknowledgement and Waiver as to Student Self-Administration and Self-Carrying of Medication By executing this provision, I/we hereby affirm and acknowledge that I/we am/are aware of the risks associated with the above named student’s self -administration and/or self-carrying of the above named medication and being so educated do hereby on behalf of myself/ourselves, my/our child, and all of my/our personal representatives knowingly agree to defend, hold harmless, indemnify, release and forever discharge Severn School, its agents and its employees from and against any and all claims, demands, and actions or causes of actions of any sort on account of damage done to personal property, personal injury or death which may occur as a result of his/her self administration and/or self-carrying of the medication named above and/or as a result of his/her failure to self-carry and/or self-administer the above named medication in the event that he/she has been authorized to self-carry and/or self-administer same. ____________________________________________________ _____________
PARENT / GUARDIAN / ADULT STUDENT SIGNATURE
C.
DATE
______________________________
______________________________
______________________________
HOME PHONE
CELL PHONE
WORK PHONE
Severn School Policy on Administration of Medication By executing this provision, I/we am/are agreeing to the following terms and conditions: a) The parent/guardian shall give the student named above (or if the student is over eighteen years he/she will give himself/herself) the first dose of any new prescription or over-the-counter medication, except for pro re nala (PRN)/emergency medication (e.g. Epi-Pen); b) The determination as to whether a student may self-carry and/or self-administer medication shall be vested with the student's parent(s)/guardian (s) (or the student himself/herself if over the age of eighteen years) and Severn School shall assume no responsibility and/or liability which may arise as a result of the parent(s)’/guardian(s)’/adult student's decision. However, Severn School by and through its agents and/or employees explicitly reserves the right to reject said parent(s)’/guardian(s)’/adult student's determination if in the discretion of Severn School a particular student's self-carrying or self-administration of a medication would be inappropriate. c) If the medication named above is a narcotic and/or scheduled, then the parent/guardian of the above named student (or the student himself/ herself if he/she is over the age of eighteen years) shall personally bring the medication directly to the school nurse and shall provide the school nurse with no more than a thirty (30) day supply of same. I/we shall be responsible for executing a new order and authorization every thirty (30) days for the administration of any non-PRN narcotic which must be administered for any period exceeding thirty (3) days. ____________________________________________________ _____________
PARENT / GUARDIAN / ADULT STUDENT SIGNATURE
DATE
______________________________
______________________________
______________________________
HOME PHONE
CELL PHONE
WORK PHONE
