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Get MD MCPS 525-13 2019-2024

Principal/School Nurse Signature MCPS Form 525-13 Rev. 12/14 DISTRIBUTION COPY 1/Student Health Record COPY 2/Parent/Guardian INFORMATION AND PROCEDURES 1. MONTGOMERY COUNTY PUBLIC SCHOOLS HEALTH AND HUMAN SERVICES Rockville Maryland 20850 AUTHORIZATION TO ADMINISTER PRESCRIBED MEDICATION Release and Indemnification Agreement PART I TO BE COMPLETED BY THE PARENT/GUARDIAN I hereby request and authorize Montgomery County Public Schools MCPS and Montgomery County Department of Health and Human Services MCDHHS personnel to administer prescribed medication as directed by the physician Part II below. I agree to release indemnify and hold harmless MCPS and MCDHHS and any of their officers staff members or agents from lawsuit claim demand or action against them for administering prescribed medication to this student provided MCPS and MCDHHS staff are following the physician s order as written in Part II below. I have read the procedures outlined on the back of this form and assume the responsibilities as required* Student Birthdate Prescription Renewal New / School If new the first full day s dosage was given at home on List all medication s student is taking including over-the-counter medication s Parent/Guardian Signature - Phone Number Date The Montgomery County Department of Health and Human Services and the Montgomery County Public Schools discourage the administration of medication to students in school during the school day. Any necessary medication that possibly can be administered before and after school should be so prescribed* Only non-parenteral medications are administered except in specific emergency situations. School personnel will when it is absolutely necessary administer medication to students during the school day and while participating in outdoor education programs and overnight field trips according to the procedures outlined on the back of this form* PLEASE USE A SEPARATE FORM FOR EACH MEDICATION Name of Medication Trade name and/or generic Dosage Ranges not accepted i*e* 1 to 2 tabs or 2 to 4 puffs Diagnosis Time s To Be Given At School Route of Administration Effective Dates From To Side Effects If PRN specify When indicated signs/symptoms Frequency of administration Physician s Name print/type Physician Signature SELF-CARRY/SELF-ADMINISTRATION OF EMERGENCY MEDICATION AUTHORIZATION/APPROVAL Self-carry/self-administration of emergency medication such as inhalers and EpiPens must be authorized by the prescriber and be approved by the school nurse according to the State medication policy Prescriber s authorization for self-carry/self-administration of emergency medication Signature School Registered Nurse RN approval for self-carry/self-administration of emergency medication Check as appropriate Parts I and II above are completed including signatures. It is acceptable if all items of information in Part II are written on the physician s stationery/prescription blank. Medication label and physician order are consistent. Over-the-counter medication is in an original container with the manufacturer s dosage label and safety seal intact.

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