Medication Declaration and Release

This authorization is valid for the duration of the participant’s enrollment unless revoked in writing. It will still apply even if the student takes a break and returns. It must be done by a legal guardian and be submitted for Mirror Image to distribute OTC drugs to your student. This includes ibuprofen/Tylenol for headaches, bodyaches, or any other pain.

This form is not required, but needed for such manners. Please note: It is against the Mirror Image Policy for students to share any type of medication on property. Any medication not listed on the form or that is being shared will be confiscated.

Child's First name

Child's Last Name

Child's DOB

Month

Day

Year

Legal Guardian First name

Legal Guardian Last Name

Emergency Phone Number

SECTION 1: AUTHORIZATION FOR OVER-THE-COUNTER MEDICATIONS (OPT-IN)

I authorize designated staff to administer only the following over-the-counter medications, as needed, and in accordance with manufacturer-recommended dosage guidelines: This authorization does not apply to any other medications.

SECTION 2: DECLARATION OF PERSONAL MEDICATIONS

Please list all prescription or over-the-counter medications the participant may bring, including emergency medications such as inhalers or EpiPens.

Please Declare Here: Must Include: Medication Name, Dosage/Instructions, Reasons, Emergency Use (Y/N)

SECTION 3: MEDICATION STORAGE & ACCESS POLICY

I understand and agree that all declared medications must be checked in and kept at the front desk while the participant is present, unless otherwise authorized in writing.

I understand that staff may assist with access to emergency medications but are not medical professionals.

SECTION 4: ACKNOWLEDGMENT & RELEASE

I acknowledge that medication will be administered in good faith and only as authorized above. I agree to release and hold harmless the organization and its owners, employees, instructors, and volunteers from liability related to the administration, possession, or storage of medication, except in cases of gross negligence or willful misconduct, as permitted under Indiana law.

I certify that the information provided is accurate and complete. I understand that if any changes are made to a student's prescription, this form must be updated.

In understand that all information listed on this form is truthful and that I agree to all terms listed above.

Guardian Signature

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