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Authorization to Dispense Medication

All medication must be delivered to the office by a parent or guardian, and a doctor's note is required in order for office staff to dispense medication. Over the counter medication must be in original packaging with printed dosages appropriate for age and/or weight. Prescription medications must be in their original container with an expiration date, properly labeled and correctly indicating the scholar's name, the name of the prescribing physician or dentist, and the instructions for administration. CBA employees may not administer medications requiring invasive procedures, such as injections. A new authorization form must be filled out for each change of medication and renewed each school year. Medication that is not reclaimed by the last official day of school will be destroyed, according to CBA policy and procedures. A separate form must be filled out for each medication.

Scholar's first name

Scholar's last name

SoonerCare number if applicable.

Name of medication

Untitled checkboxes field

Medical diagnosis

Dates and times for medication to be administered

Amount of medication to be administered

Date of prescription

Discontinuation date

Expected side effects

Plan to manage side effects

Amount of medication provided to CBA (e.g. number of pills)

Parent/Guardian Authorization: I hereby authorize College Bound Academy and its designated employees to administer to my child lawfully prescribed medication in the manner described above. I acknowledge that it may be performed by an individual other than a school nurse, and specifically consent to such practices I acknowledge and agree that I waive any claims that I might have against College Bound Academy and its employees arismg out of the adm1mstration of said medicine. I agree to hold harmless its designated employees from and against any and all claims, damages, causes of action or inJurtes incurred or resulting from the administration, attempts at administration or om1ss1ons of said medicine pursuant to the proV1sions of Oklahoma law, except for acts or omissions constituting gross, willful, or wanton negligence.

Parent/Guardian full name

Parent/Guardian signature

Signature

Today's date