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Medical release form

Self Medication Order for Benadryl Only
The administration of medication to a child during the before and after school SACC Program will be
permitted only when the child’s physician certifies in writing that the administration of medication
during the before and after school SACC Program is essential to the health of the child and may be
self-administered by the child safely. The parent/guardian must provide a written request for the
self-administration of the prescribed medication.
Part I – To Be Completed In Full By the Child’s Physician

I certify that it is essential to the health of _____________________________that the following
medication be administered during the before and after school SACC Program.
DIAGNOSIS:______________________________________________________________________
NAME OF MEDICATION:___________________________________________________________
DOSAGE/MODE/FEQUENCY:________________________________________________________
SIDE EFFECTS, if any:_____________________________________________________________
PERMISSION IS GRANTED FOR SELF-MEDICATION BY THE CHILD. THE CHILD HAS BEEN
TRAINED AND IS PROFICIENT IN SELF–ADMINISTRATION OF PRESCRIBED MEDICATION, WHICH
MAY BE ADMINISTERED BY THE CHILD SAFELY.
LENGTH OF TIME THE ORDER IS VALID (may not exceed the school year):_______________________
__________
_______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________
PART II – To Be Completed By the Child’s Parent/Guardian:


I hereby request self-medication privileges for my child___________________________________.
He/she has received instruction in and will demonstrate correct procedures in the use of the
prescribed medicine to me and or his/her personal physician. My child and I are also aware that
self management privileges are lost if the child does not use the medication properly. Provided they
are informed, the SACC staff will employ their best efforts to report to the school nurse after the
child’s use of medication in the form of a self-medication written form. This reporting to the school
nurse may take place that day of self medication or the next day. Best efforts will be utilized by
SACC to timely notify the parent of the child’s self medication event.
I also understand that the Monmouth-Ocean Educational Services Commission and its employees
or agents shall incur no liability as a result of injury arising from the self-administration of medication
by the child and, as a consequence, I release and waive any right I may have or cause of action which
may arise as a result of self-medication. The parents or guardians shal indemnify and hold harmless
the Monmouth-Ocean Educational Services district and its employees or agents against any claims
arising out of the self-administration or medication by the child.
____________ _______________________________________________________
_______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

Source: http://www.moesc.org/Files/SACC/BenadrylForm.pdf

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