2024 - 25 Medication Release Form

Required

Student's required

First Name

Last Name

Graderequired

Please list any medications you DO NOT want administered.

Please list any drug allergies?required

Emergency Contact Namerequired

Emergency Contact #required

Does your child have allergies that require an Epi-Pen?required

Yes

When was the last time your child experienced anaphylaxis?required

Where would you prefer your child's Epi-Pen located during school hours?required

Nurse's office (Please supply Epi-Pen to school nurse on orientation day.)

With my child

Both (Please supply 2 Epi-Pens on orientation day.)

Does your child have asthma that requires an inhaler?required

Yes

Where would you prefer your child's inhaler located during the school hours?required

Nurse's office (Please supply the school nurse with an inhaler orientation day.)

With my child

Both (Please supply 2 inhalers on orientation day.)

By typing my name below, I hereby release, relieve and discharge St. Thomas More Catholic High School and its employees from any and all liability for any injury, illness or damage to health of said student arising out of or resulting from the necessity of said student having to take medication during school hours. I also authorize the school nurse to administer over the counter medication to my child as she sees fit for any illness or injury occurring at St. Thomas More Catholic High School.

Parent/Guardian Signaturerequired