Common Contracts
1 similar Authorization to Administer Prescribed Medication contracts
ContractAuthorization to Administer Prescribed Medication • April 27th, 2001
MONTGOMERY COUNTY PUBLIC SCHOOLS MONTGOMERY COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICESRockville, Maryland 20850 AUTHORIZATION TO ADMINISTER PRESCRIBED MEDICATIONRelease 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 (DHHS) personnel to administer prescribed medication as directed by an authorized prescriber (Part II below). I agree to release, indemnify, and hold harmless MCPS and DHHS 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 DHHS staff are following the authorized prescriber’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 Name: Birthdate: / / School: -- Choose One -- Prescription: □
