Attachment_I_Medication_Release_Form.pdf

Medication Release Form

Name of EFM:___________________________

Medication: _______________________________

Dosage: ___________ (Amount and times during the day)

Special Instructions (including any special storage requirements and noting any side effect(s) of which Strategic Resources, Inc. should be aware)

Reason for the medication: _________________________________________________

Date: _____________________ Name of Physician: _____________________________

Signature of Physician: _____________________________________________________

PARENTAL CONSENT AND WAIVER

I hereby give my permission for my child ___________________________ to be given the above prescribed medication by the respite care provider.

Notice: All medicine left for issuance by the respite care provider must be in the original container, appropriately labeled by the pharmacy or physician.

WAIVER OF LIABILITY

I understand that the respite care provider will administer only the prescribed medication mentioned above. I hereby waive any and all claims against Strategic Resources, Inc. and agree to hold Strategic Resources, Inc. harmless from any and all liability, which may arise in connection with my child’s use of the medication.

Parent or Guardian’s Signature _________________________________ Date: ________

Attachment I