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315

Appendix II - Request for Administration of Medication - Form 315-2

Procedures

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)

 

 

Per:_____________________________________________

 

 

Per:_____________________________________________

 

 

Dated at ___________________________ this ______ day of _________________, 2_____.

                       (Location)                                (day)                    (month)               (year)

 

 

 

 

 

Administrative Procedure 315 – Form 315-2

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October, 2009