Common use of Healthcare Provider Clause in Contracts

Healthcare Provider. The student named above meets the CMS eligibility requirements for self-medication. This student is capable of, has been instructed on the procedures for and has demonstrated the skill to self-administer this medication as directed in Section 1 of this form. This student will not require adult supervision while taking this medication. Check applicable items below: ❒ This medication is a controlled substance. ❒ Please allow this student to self-administer this medication while at school during school hours. ❒ This student should always carry this medication with him/her during the school day, while at school-sponsored events, or while in transit to or from school or school-sponsored activities. My child is capable of self-medicating and meets the CMS eligibility requirements. I give consent to the Charlotte-Mecklenburg Schools to allow my child to self- administer this medication at school. I understand that my child and I assume responsibility for the proper use and safekeeping of this medication. I will ensure my student carries the correct and non-expired medication to school. If this medication is for a life-threatening emergency such as anaphylaxis or asthma, I agree to provide a backup supply of the medication to be kept at school in a location to which my child has immediate access to assure the medication is available if needed. I release the Charlotte-Mecklenburg Board of Education, their agents, and employees from all liability whatsoever that may result from my child carrying or taking this medication at school. I understand that information about this medication and my child’s health may be shared with other school staff and agents of the school to help assure my child’s safety and success at school. The school nurse may contact the healthcare provider who prescribed the medication and the pharmacy where the prescription was filled to discuss this medication and my child’s health. I am capable of taking this medication on my own. I agree to take this medication as ordered. I will keep it safe and out of the sight of others when I am not using it. I will not let others hold or use my medication or medical supplies. I understand that I will be disciplined under the CMS Student Code of Conduct if I abuse the privilege of being allowed to self-medicate while at school or school sponsored activities. I understand that I may lose the privilege of self-administering my medication if I do not follow these rules. I understand that if I self-administer my medication and my symptoms do not improve, I will notify the school nurse or other CMS staff. I have reviewed this request and acknowledge that this student has demonstrated the skill level to self-administer this medication and has the correct and non-expired medication with them at the time of signage of this document. I have informed this student that he or she must tell an appropriate staff member whenever he or she has used the medication at school. Nurse Signature: Date: I have reviewed this request and approve this student for self-administering this medication. Date: Principal/Designee Signature and Print Name: Form med 01 | 6/24 rnl 9 Return completed form to: CMS School Nutrition Services PO Box 668847 Charlotte, NC 28266 Phone (000) 000-0000 Fax (000) 000-0000 xxxxxxxxxxxx@xxx.x00.xx.xx 9154476286 * Monthly menus with carbohydrate content in grams and major food allergens are posted at xxxx://xxx.xxxxxxxxxx.xxx. A completed Diet Order Form is not required if nutrislice information is sufficient for parent/guardian to manage a student's diet at school. (El menú mensual, con la información sobre los gramos de carbohidratos y los principales alérgenos de los alimentos se encuentra en xxxx://xxx.xxxxxxxxxx.xxx. No es necesario completar esta planilla si la información mencionada en nutrislice es suficiente para que los padres/tutores supervisen la dieta del estudiante en la escuela)

Healthcare Provider. The student named above meets the CMS eligibility requirements for self-medication. This student is capable of, has been instructed on the procedures for and has demonstrated the skill to self-administer this medication as directed in Section 1 of this form. This student will not require adult supervision while taking this medication. Check applicable items below: ❒ This Is this medication is a controlled substance. ? ❒ yes ❒ no ❒ Please allow this student to self-administer this medication while at school during school hours. ❒ This student should always carry this medication with him/her at all times during the school day, while at school-sponsored events, or while in transit to or from school or school-sponsored activities. My child is capable of self-medicating and meets the CMS eligibility requirements. I give consent to the Charlotte-Mecklenburg Schools to allow my child to self- administer this medication at school. I understand that my child and I assume responsibility for the proper use and safekeeping of this medication. I will ensure my student carries the correct and non-expired medication to school. If this medication is for a life-threatening emergency such as anaphylaxis or asthma, I agree to provide a backup supply of the medication to be kept at school in a location to which my child has immediate access to assure the medication is available if needed. I release the Charlotte-Mecklenburg Board of Education, their agents, agents and employees from any and all liability whatsoever that may result from my child carrying or taking this medication at school. I understand that information about this medication and my child’s health may be shared with other school staff and agents of the school to help assure my child’s safety and success at school. The school nurse may contact the healthcare provider who prescribed the medication and the pharmacy where the prescription was filled to discuss this medication and my child’s health. I am capable of taking this medication on my own. I agree to take this medication as ordered. I will keep it safe and out of the sight of others when I am not using it. I will not let others hold or use my medication or medical supplies. I understand that I will be disciplined under the CMS Student Code of Conduct if I abuse the privilege of being allowed to self-medicate while at school or school sponsored activities. I understand that I may lose the privilege of self-administering my medication if I do not follow these rules. I understand that if I self-administer my medication and my symptoms do not improve, I will notify the school nurse or other CMS staff. I have reviewed this request and acknowledge that this student has demonstrated the skill level to self-administer this medication and has the correct and non-expired medication with them at the time of signage of this documentmedication. I have informed this student that he or she must tell an appropriate staff member whenever he or she has used the medication at school. Nurse Signature: Date: I have reviewed this request and approve this student for self-administering this medication. Date: Principal/Designee Signature and Print Name: Form med 01 | 6/24 rnl 9 Medical Statement for Students with Unique Mealtime Needs for School Meals Return completed form to: CMS School Nutrition Services PO Box 668847 Charlotte, NC 28266 Phone (000) 000-0000 Fax (000) 000-0000 xxxxxxxxxxxx@xxx.x00.xx.xx 9154476286 DO NOT WRITE IN THIS AREA 1893540213 Parent/Guardian: It is REQUIRED that this completed form be returned to CMS School Nutrition Services. This form must be completed by a state licensed authorized medical authority each time student's diagnosis or change of treatment is indicated. This written statement will remain in effect until the parent or legal guardian revokes such statement. (Padre/madre/tutor: Se REQUIERE que se devuelva esta planilla debidamente completada a CMS School Nutrition Services. Este formulario debe ser completado por una autoridad médica autorizada con licencia estatal cada vez que se indique un diagnóstico o un cambio de tratamiento del alumno. Esta declaración escrita permanecerá en vigencia hasta que el padre/madre/tutor revoque dicha declaración.) * Monthly menus with carbohydrate content in grams and major food allergens are posted at xxxx://xxx.xxxxxxxxxx.xxx. A completed Diet Order Form is not required if nutrislice information is sufficient for parent/guardian to manage a student's diet at school. (El menú mensual, con la información sobre los gramos de carbohidratos y los principales alérgenos de los alimentos se encuentra en xxxx://xxx.xxxxxxxxxx.xxx. No es necesario completar esta planilla si la información mencionada en nutrislice es suficiente para que los padres/tutores supervisen la dieta del estudiante en la escuela)