For the safety of all students, it is preferred that medications be stored securely and administered by trained staff. However, at times, a parent/guardian may thoughtfully decide that their child needs to carry their medication at school.

• To self-carry medication, the student must be able to self-administer without any assistance or reminders.
• Only five day's doses may be carried unless, as in the case of inhalers or multi-dose packaging, such a request is impossible.
• The medication must be in the original labeled container from the pharmacy or manufacturer.

This Authorization Form is required for all prescribed and over-the-counter medications, with certain exceptions noted in italics below. One form may be used to cover an entire week/ month/year for medication use "as needed."

The building principal/designee has the right to further restrict medications that are self-carried. A student that is not using their medication responsibly may lose their right to carry medication and be subject to disciplinary proceedings.

This agreement must be signed and kept in the student's possession at school prior to the granting of permission to self-administer medication.

I give permission for my child to self-administer the medication described below. As the parent/guardian I agree to indemnify, defend, and hold the School District harmless from any and all claims, actions, costs, expenses, damages, and liabilities, including attorney's fees, arising out of, connected with, or resulting from the self-administration of medication by the pupil. As the parent/guardian I agree that the School Board, School District and its employees and agents shall incur no liability as a result of any injury arising out of or connected with the self-administration of medication by the pupil. Specifically, as the parent/guardian I agree that I will not institute either on my behalf or on behalf of the pupil, any claim or action against the School District, School District employees and its agents arising out of or connected with self-administration of medication by the pupil. This agreement shall take effect on the date listed below and shall stay in effect for as long as the pupil is provided permission to self-administer medication. This agreement must be signed and in full effect prior to the granting of permission to self-administer medication.

Any student who is permitted to self-administer a prescribed inhaler, an epinephrine auto-injector, insulin or blood glucose monitoring shall be permitted to possess and use a prescribed inhaler, an epinephrine auto-injector, insulin or blood glucose monitoring supplies at all times, pursuant to Idaho Code 33-520. This form is not needed for a prescribed inhaler, an epinephrine auto-injector, and insulin or blood glucose monitoring supplies.

Form (3510F4) Rev. (5/20)