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<br /> <br /> <br />Self-Administration of Oral Medication <br />Authorization <br />(References: P.108.SCO, PR.548.SCO and PR.632.SCO) <br />NOTE: Please type and submit the original, signed copy to your child’s school principal in a <br />timely manner. In the case of ongoing serious medical conditions (such as but not limited to <br />severe, life-threatening allergies, diabetes, epilepsy, heart condition, asthma), this <br />authorization will terminate on June 30 of each school year. Please ensure to notify the <br />principal if the prescription changes or expires. This authorization may be cancelled upon <br />receipt of w ritten notification to the principal. <br />School Name: Date: <br />Principal’s Name: Teacher’s Name: <br /> <br />ADVISEMENT OF ADMINISTRATION OF ORAL MEDICATION <br />Student’s Name: Student No.: <br />Parent/Guardian (if student is under 18 years of age): <br />Telephone (Home): Telephone (Business): <br />Address: <br />E-mail Address: <br />Physician’s Name: Physician’s Telephone: <br /> <br />PHYSICIAN’S ST ATEMENT RE: ADMINISTERING ORAL MEDICATION DURING SCHOOL <br />HOURS <br />In my opinion, it is necessary that the following medication be administered during school hours: <br />1. Name of Medication: <br />2. Storage Cautions, if any: <br />3. Dosage of Medication: <br />4. Time of Administration: <br />5. Special instructions for Administration: <br />6. Duration of Medication Regime: <br />7. Caution of Notable Side Effects: <br /> <br />Physician’s Signature: Date: <br /> <br />PARENT/GUARDI AN AUTHORIZATION RE: SELF-ADMINISTRATION <br />The responsibility for administration of medication involves certain elements of risk. Unexpected <br />consequences including, but not limited to, illness, adverse reactions or other complications may <br />occur as a result of the administration (or non-administration) of any medication. These physical <br />reactions result from the medication and can occur without fault on the part of the student. By <br />requesting and consenting to the self -administration of medication, you are assuming the risk of an <br />unexpected reaction occurring. It is understood that the chances of such a reaction occurring may be <br />reduced by carefully following the instructions provided by the physician and/or pharmacy at all times. <br />If you consent to the self -administration of medication, you must understand that you will bear sole <br />responsibility for any physical reaction that might occur. <br />I have read the above and I understand that in requesting and consenting to the self -administration of <br />OCDSB 285 School Operations (June 2014) Confidential W hen Complete <br />Page 1 of 2 <br />Distribution: OSR <br />