Metz Clinic Fax 703-257-8590
Medication Consent Form
Manassas City Public Schools
PART I (To Be Completed by the Parent/Guardian)
I hereby authorize the Manassas City Public Schools (MCPS) personnel to administer medication as directed by this authorization. In the absence of gross negligence or willful misconduct, I agree to release, indemnify, and hold harmless the City of Manassas Public Schools and any of their officers, employees, or agents from lawsuit, claim, expense, demand or action, etc., arising from the administration of medication, provided MCPS staff comply with the physician's or parent/guardian's orders set forth in accordance with Part II below. Parent/ guardians should not assume that medications will always be administered by the school nurse. If a school nurse in not available, it will be necessary for medication to be administered by a staff member who is not a health care professional. Therefore, it is vital that directions, dosage and expiration date of the medication be clear. I have read the procedures outlined and assume responsibilities as required.
PART II (To be completed by phsician for all long-term medications and over-the-counter medications that exceed five days. To be completed by parent/guardian for short-term medications and over-the-counter medications taken less than five days in succession.) All medications must be in the original conatiner, including all over-the counter medications.
PART III (To be completed by the school staff/principal designee accepting this medication.)