LADYWOOD HIGH SCHOOL

LADYWOOD HIGH SCHOOL
A Ministry of the Felicieri Sisters
14680 Newburgh Road • Livonia, Michigan 48154-5099
(734) 591-1545 • Fax: (734) 591-4214
Dear Parents/Guardians,
According to the Michigan School Code section #1178, dispensing of medication
in the school
can only be done by a licensed professional, or an employee designated by the school administrator
the presence of another person and ONLY with the written
AND physician. This includes all medication.
authorization
This includes all medications
in
of the parent / guardian
(prescriptions
and over the
counter medications such as Tylenol, Motrin, ETC.
According to policy, Ladywood High School prohibits the carrying of medications of any kind by a
student. All medications
must be brought to the main office first thing in the morning and kept there
until the end of the day or until the prescription
is no longer needed. The only exceptions are inhalers
and epi-pens which may be kept with the student and only if indicated on the signed form and on file in
the main office.
Attached to this letter is the release for Dispensing of Medication
Form. This form must be filled
out by your daughters physician (in ink) and signed by the physician AND parent or guardian in order
for your daughter to receive any type of medication.
NO EXCEPTIONS.A stamp of the physician or clinic
must be included on the form when it is being filled out.
The forms may be dropped off at the office ATTN: Kathy Charnley. More forms may be obtained
from the main office if needed. If you have any questions, please feel free to call me.
Thank you for your cooperation
Sincerely,
Kathy Charnley
Office Manager Ladywood High School
734-591-1544
on this matter.
RELEASE FOR DISPENSING OF MEDICATION
We, the undersigned parent and/or guardian of:
_____
(Student's Name)
do hereby sign and
son/daughter/ward.
Bom
(Grade/Room #)
execute
this
release
on
behalf
Mo
of
us
/_/
__
Day
and
Yr
on
behalf
NAME OF MEDICATION:
of our
minor
_
DOSE:
_
TIME TO BE GIVEN:
_
DURATION:
_
ATTACH DOCTOR'S NOTE REGARDING ADMINISTRATION
OF MEDICATION
o Check here, and attach emergency care plan, if this
release is for a metered dose asthma
inhaler, which the student will possess and use at his/her own discretion in school or at
school activities. The physician and parents/guardian signature below apply to the inhaler
possession and use by students as permitted in Public Act 10 - Revised School Code.
(Doctor's Signature)
(Please Print Name)
(
(Date)
)------------------(Phone Number)
We hereby waive any liability whatever to the school or the Archdiocese of Detroit or any of its
personnel, that might occur as the result of giving said medication in the indicated dosage at the time
requested to our minor son/daughterlward.
PARENT/GUARDIAN
(Signature)
(Print Name)
DATE
Aug. 2007
_