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Student's Name (Last), (First), (Middle) Birthday School Date
The district seeks to provide a safe environment for students, staff, and visitors who are at risk of potentially life-threatening incidents. The district supplies the following prescription medications for life threatening incidents that are listed below. Generic brands may be substituted, (select all that apply):
• Epinephrine auto-injectors
• Bronchodilator
• Bronchodilator Canisters and Spacers
• Opioid Antagonist
Pursuant to state law, the school district or and its employees are to incur no liability for any injury arising from the provision, administration, failure to administer, or assistance in the administration of the selected prescription medications supplied by the school for life threatening incidents provided they have acted reasonably and in good faith.
The parent or guardian shall sign consent for the student to receive the voluntary school supply of stock medication listed for life threatening incidents and sign a statement acknowledging that the school district is to incur no liability as a result of administration of a prescription medication for life threatening incidents provided the school district to have acted reasonably and in good faith. Electronic signature meets the requirement of written signature.
• I request the above-named student be administered the voluntary stock supply of prescription medication, in the name of the school district, by a school nurse or personnel trained and authorized to administer to a student who acting reasonably and in good faith perceives the student may be experiencing symptoms associated with a life threatening incident following the administration instructions listed as identified in the required annual awareness training associated with the stock medication(s) above and after completion of the medication administration course requirements
• I understand the school district and its employees acting reasonably and in good faith shall incur no liability as a result of administration of the prescription medication(s) for life
threatening incidents provided the school district to have acted reasonably and in good faith.
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Parent/Guardian Signature Date
(agreed to the above statement)