Appendix II - Request for Administration of Medication - Form 315-2
Request for Administration of Medication
I ____________________________, parent/guardian of _________________________
(name of parent/guardian) (name of student)
have requested and authorized the staff or agents of Northern Gateway Regional Division No. 10 to provide assistance and/or administration of medication to the above mentioned student.
I ___________________________ release Northern Gateway Regional Division No. 10
(name of parent/guardian)
and its staff or agents from all actions, causes of action, suits, demands and claims of whatsoever nature, with respect to the administration of any treatment to
______________________________ in such circumstances.
(name of student)
The undersigned specifically acknowledges that the staff and agents of the Board referenced herein are not medical personnel.
Signatures of Parent(s)/Guardian(s)
Dated at ___________________________ this ______ day of _________________, 2_____.
(Location) (day) (month) (year)
Administrative Procedure 315 – Form 315-2
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