PARENT RELEASE FOR ADMINISTRATION OF
PHYSICIAN-PRESCRIBED SERVICES

St. Irene School recognizes the desirability of following a physician’s recommendations for physician-prescribed services (PPS) at school whenever possible.

The fact that this is a service accommodation which the school is not legally required to perform is recognized by all parties signing this form, and in so signing they agree to hold the school and its staff free from any liability which might otherwise arise out of these arrangements. PPS which can be administered before or after school instead of during the school day will not be administered by school staff. We (I) understand that the school is not required by law to provide physician-prescribed services (PPS) to our (my) child and, therefore, in consideration of the school’s agreeing to administer such PPS we (I) agree to hold the school and its employees free from any and all responsibility for the results of such PPS or the manner in which it is administered and to indemnify each of them against loss by reason of any civil judgement arising out of these arrangements which may be rendered against them.

We (I) agree to provide the school with necessary equipment and supplies properly labeled, with proper directions for use in school.

We (I) the undersigned, who are the parent(s)/guardian(s) of ___________________________

request that PPS be administered to our child in accordance with he instructions of our physician Dr. __________________________________________, as set forth on the Physician’s Order for Physician-Prescribed Services. We (I) understand that such PPS is to be administered by a member of the school staff to be designated by the Principal.

We (I) will notify the school immediately if we change physicians or if this PPS shall stop. You are requested to continue such PPS until notified by us (me) or the physician named above to discontinue such PPS and where such notice is given orally, it shall be confirmed within 24 hours.

We are (I am) aware that this PPS may be administered by non-medically trained staff.

We (I) hereby grant permission for the student’s physician(s) and the schools staff to directly communicate.

We (I) certify that the above-named physician is aware of all medication currently being administered to this child.

The school is authorized to secure emergency medical services for my child whenever the need for such services is deemed to be necessary by the principal or school staff member.

Father’s (guardian’s) name ________________________________________________________

Father’s address___________________ home phone_______________ business phone________

Signature of father/guardian _____________________________ Date ____________________

Mother’s (guardian’s) name _______________________________________________________

Mother’s address __________________ home phone________________ business phone_______

Signature of mother/guardian______________________________ Date ___________________

(Both parents must sign this form if they are living with or have custody of the child)

School Contact Person _________________________ Phone ___________________________

Approved as to form. This approval in no way relates to the medical directions or the physician’s reasons therefore.

Principal or designee _______________________________ Date _________________________