MADISON SCHOOL DISTRICT
Madison High School, Madison Junior School
Central Avenue School, King, Road School, Torey J. Sabatini School
Indemnification for Medication Self Administration
Student Name _________________________________Date________________________
Medication_____________________________________
In accordance with N.J.S.A. 18A:40-12.3, a pupil is permitted to self-administer
medication for asthma or other potentially life-threatening illnesses. This is to confirm that
the district shall incur no liability as a result of any injury arising from the selfadministration of medication.
The parent/guardian indemnifies and holds the district and
its employees harmless against any injury or claims that arise as a result of the pupil’s selfadministration of medication.
Mother or Guardian________________________________________
Father or Guardian_________________________________________
Principal_________________________________________________