Medication Information (to be completed by Physician on separate form)
Corban Academy and Kona Faith Center, Inc. employees and staff members are not authorized to hand medication to students unless parents/legal guardians give explicit, written permission on this form.
All medications are to be kept in the original containers with the physician's and student's names, the dosage, and the instructions clearly printed on the container. (If medication is over-the-counter, the medication must be kept in its original container.)
It is the parent's/legal guardian's responsibility to ensure Administration has any special instructions necessary when verifying the medication. All special instructions must be listed above by the student's physician.
The student is ultimately responsible for taking/administering his/her own medication. Staff members may verify the medication and hand it to the student.
At this time, Corban Academy Staff is not equipped to administer medication directly to the student or to care for students with extensive medical needs.
Only parents/legal guardians may transport medications to Administration. Students may not transport medications to Administration.
Since this is a service provided by the academy, Corban Academy reserves the right to reject any request for medication administration, based on nondiscriminatory reasons. Such reasons may include but are not limited to: medication not in its original container, expired medications, etc.
In consideration of my (or my student's) participation in Corban Academy Staff handing medication and other valuable considerations, the receipt of which is acknowledged, I hereby agree to accept all risk of my health and of my injury or death that may result from such participation and I hereby release, waive, discharge and covenant not to sue Kona Faith Center, Inc., and Corban Academy their directors, officers, employees, volunteers, and agents (hereinafter referred to as “Releasees”) from all liability to me, my personal representatives, assigns, heirs, next of kin or anyone else for any loss or damage in any claim or demands therefore, on account of property damage, personal injury or death, whether caused by the negligence of the Releasees or otherwise, arising out of any activity related to this event, including travel to and from this event to the fullest extent permitted by law.
The Releasees are not responsible for any adverse reactions that may occur from taking any personal medications. I understand that Corban Academy Staff may not be medically trained to administer the medication specified in this form. I hereby assume full responsibility and risk of bodily injury, death or property damage arising out of participation in Corban Academy Staff administering the medication specified on this form. I understand that there are certain risks that may occur both known and unknown including but not limited to: exposure to personal injury; accident or illness; forces of nature; overdose; loss or waste of medication; improper administration of medication.
I authorize Corban Academy and Kona Faith Center, Inc. employees and staff members to hand medication to my child (the student) listed on this form.