LIBERTY SCHOOL DISTRICT
Contract for Self Carried Medication
Student:___________________________DOB:____________ School: ___________________Grade:______
Medication: ________________Dose: ___________ Frequency: _______________
Directions for use: ______________________________________________________
Self-carried emergency medications are permitted in accordance with state law and school district policy.
Each student’s physician and parent/guardian must authorize self carried/administered medication.
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I understand that I must provide the Liberty School District with an Authorization for Administration of
Oral Medication at School Form for this emergency medication signed by myself and my student’s
Licensed Healthcare Provider.
I understand that the Medication Form must be renewed each school year.
I understand that I am responsible for providing the prescribed emergency medication for my student in
its original container with the prescriptive label attached.
I understand that the medication must be current and not past its expiration date.
I understand that the Liberty School Board of Directors or its employees cannot be held responsible for
negative outcomes resulting from my student’s self-administration of their emergency medications.
I understand that the School Nurse will work with me to prepare an Emergency Care Plan and/or
Individualized Health Plan for my student while at school. This plan will be reviewed and signed by
both my student’s Licensed Healthcare Provider and myself.
I understand that the School Nurse will also train specified non-licensed school staff to assist my
student in the administration of his/her emergency medications.
I understand that the School Nurse recommends that we provide back-up emergency medications in
the school office.
I understand that I do not have to provide back-up medications for the school.
I understand that if I do not wish to provide back-up medications for the school, my student will be
required to demonstrate to the bus driver or school secretary (if driving or driven to school) that they
have their medications on their persons as they board the bus or arrive at school. If they do not have
their emergency medications with them, I understand that I will be notified to pick them up from school
or bring their emergency medications to school for them.
I understand that my student athlete will also have to demonstrate to their coach that they are carrying
their emergency medications on their persons in order to participate in athletics.
I understand that the School Nurse will review with my student his/her knowledge of their health
concern, the proper and prescribed timing for using the emergency medications and the correct
administration of the emergency medications.
I understand that my student must demonstrate the correct use, timing and administration of their own
emergency medications before they will receive permission to self-carry those medications.
I understand that that the permission to possess and self-administer emergency medication may be
revoked by the principal if it is determined that my student is not safely and effectively selfadministering their own medication.
I will support my child to follow the above agreement and if she/he does not, I will be contacted and we will
develop a new plan. Date: _______________
Daytime Telephone: _________________
Parent/Guardian Signature: _______________________________________________________
(Student portion continued on back)
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I have demonstrated to the School Nurse the correct administration of my emergency medications.
I understand that if there are no back-up emergency medications for me at school, I will need to show
the bus driver or the school secretary that I have my medications with me in order to board the bus or
enter the building.
I understand that, as an athlete, I will also have to demonstrate to their coach that they are carrying
their emergency medications on their persons in order to participate in athletics.
I understand what symptoms I have when I need to use my inhaler.
I agree that if there are no improvement in my symptoms after self-administering my medication, I will
report to the School Nurse or another appropriate staff member,
I agree never to share my inhaler with another person or use it in an unsafe manner.
The student may carry the medication unless or until the student fails to follow the above agreement.
Student Signature: ________________________________________ Date: _____________________
School Nurse Signature: ___________________________________ Date: ______________________