ContractAuthorization to Administer Prescribed Medication • January 29th, 2022
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 (MCDHHS) personnel to administer prescribed medication as directed by the physician (Part II below). I agree to release, indemnify, and hold harmless MCPS and MCDHHS 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 MCDHHS staff are following the physician’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: Birthdate: / / School: Prescription: # Renewal # New If new, the first full d
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 the 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: Birthdate: / / School: Prescription: □ Renewal □ New If new
Release and Indemnification AgreementAuthorization to Administer Prescribed Medication • February 1st, 2019
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 the physician (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 physician’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: Birthdate: / / School: Prescription: □ Renewal □ New If new, the first full day's d
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: □
Release and Indemnification AgreementAuthorization to Administer Prescribed Medication • April 5th, 2018
Medication that can be administered before and after classes/camps should be so prescribed. COCA staff will, when it is absolutely necessary, administer medication to students during the class/camp session, according to the procedures outlined on the back of this form. PLEASE USE A SEPARATE FORM FOR EACH MEDICATION
Release and Indemnification AgreementAuthorization to Administer Prescribed Medication • April 5th, 2018
Medication that can be administered before and after classes/camps should be so prescribed. COCA staff will, when it is absolutely necessary, administer medication to students during the class/camp session, according to the procedures outlined on the back of this form. PLEASE USE A SEPARATE FORM FOR EACH MEDICATION
