NOTE: While Colorado school districts are not required by law to adopt an exhibit on this subject, this exhibit reflects legal requirements school districts must follow. This sample exhibit contains the policy content/language that CASB believes best meets the intent of the law. However, the district should consult with its own legal counsel to determine appropriate form that meets local circumstances and needs.
Name of student _________________________________________
School ________________________________ Grade __________________
Medication ______________________________ Dosage ________________________
Purpose of medication _____________________________________________________
Time of day medication is to be given _____________________________________
Possible side effects _______________________________________________________
Anticipated number of days it needs to be given at school ________
Date _______________ _______________________________
Signature of health care practitioner
It is understood that the medication is administered solely at the request of and as an accommodation to the undersigned parent or guardian. In consideration of the acceptance of the request to perform this service by the school nurse or other designee employed by the _____(name of school district)_____, the undersigned parent or guardian hereby agrees to release the __(name of school district)____ and its personnel from any legal claim which they now have or may hereafter have arising out of side effects or other medical consequences of the medication.
I hereby give my permission for ____(name of student)____ to take the above medication at school as ordered. I understand that it is my responsibility to furnish this medication.
Date _____________ _______________________________
Signature of parent or guardian
NOTE 1: The prescription medication is to be brought to school in a container appropriately labeled by the pharmacy or health care practitioner stating the name of the medication and the dosage.
NOTE 2: Those personnel administering medications must be trained in observing for side effects and in the appropriate steps to take should side effects occur. While the school is not responsible for the occurrence of side effects, the school is responsible for observing for side effects.
[Revised July 2010]
COLORADO SAMPLE EXHIBIT 1995