NASHUA SCHOOL DISTRICT

NASHUA SCHOOL DISTRICT
NASHUA, NEW HAMPSHIRE

MEDICATION AUTHORIZATION AND HOLD HARMLESS AGREEMENT
FOR OVER-THE-COUNTER MEDICATIONS

To The Nashua Board of Education:

We the undersigned are the parents (guardians) of ______________________________ child enrolled in the Nashua School District who lives with us at ______________________________ in Nashua, New Hampshire. This child is a student at _______________________ School in the Nashua school system.

We feel that our child may benefit from the following over-the-counter medications (not to include herbal preparations or dietary supplements) and wish to have an appropriate person assist our child in taking the medication furnished by us in accordance with the printed instructions on the manufacturer’s labeled bottle we have provided. We understand that if a higher dose than what the manufacturer recommends is needed, that a doctor’s note, so authorizing the increased dosing will be provided by our child’s medical provider or pediatrician.

__________________________________________________________ NEEDED FOR ________________________
NAME OF MEDICINE, DOSE AND INSTRUCTIONS FOR TAKING REASON TAKING

This permission is good for one school year unless otherwise specified for a specific condition lasting less than one (1) school year.

We hereby agree to indemnify and hold forever harmless the City of Nashua, the Nashua School Board of Education, and their respective officials, agents, servants and employees against loss from any and all claims, demands, or actions in law or in equity that may hereafter at any time be made or brought by said minor or by anyone on behalf of said minor for the purpose of enforcing a claim for damages on account of any injuries or loss sustained in consequence of the aforesaid assistance, and we do hereby waive any and all rights of exemption, both as to real and personal property, to which we may be entitled under the laws of this or any other state as against such claim for reimbursement or indemnity.

______________________________________ _________________________________________
Signature of Parent or Guardian Address

______________________________________ _________________________________________
Signature of Parent or Guardian Date Phone

NOTE: PLEASE READ THE ABOVE CAREFULLY BEFORE SIGNING. NO CHILD WILL BE ASSISTED IN TAKING MEDICATION UNTIL THIS FORM HAS BEEN SIGNED AND DELIVERED TO THE SCHOOL WITH THE MEDICATION PROPERLY LABELED BOTTLE FROM THE MANUFACTURER. MEDICATION SHOULD BE DELIVERED TO THE SCHOOL BY THE PARENT OR GUARDIAN AND SHOULD HAVE THE CHILD'S NAME MARKED ON THE CONTAINER.