RELEASE FOR DISPENSING OF MEDICATION

We, the undersigned parent and/or guardian of:

____________________________________    ____________ Born _____/____/_____
      (Student's Name)			          (Grade/Room #)           Mo   Day     Yr

do hereby sign and execute this release on behalf of us and on behalf of our minor son/daughter/ward.

NAME OF MEDICATION:	

                              DOSE:	

        TIME TO BE GIVEN:	

                      DURATION:	

ATTACH DOCTOR’S NOTE REGARDING ADMINISTRATION OF MEDICATION

o Check here, and attach emergency care plan, if this release is for a metered dose asthma inhaler, which the student will possess and use at his/her own discretion in school or at school activities.  The physician and parents/guardian signature below apply to the inhaler possession and use by students as permitted in Public Act 10 – Revised School Code.

_________________________  ___________________________  __________
           (Doctor's Signature)                    (Please Print Name)                   (Date)

                                                     ___(_____)___________________________
                                                                          (Phone Number)

We hereby waive any liability whatever to the school or the Archdiocese of Detroit or any of its personnel, that might occur as the result of giving said medication in the indicated dosage at the time requested to our minor son/daughter/ward.

	PARENT/GUARDIAN  	_	
			         (Signature)

				
			         (Print Name)

                                                 DATE  	

Aug. 2007