PART I – TO BE COMPLETED BY PARENT/GUARDIAN

I hereby request and authorise St. Luke’s Academy personnel to adminster prescribed medication as directed by the authorised presciber (Part II below). I agree to release, indeminify, and hold harmless St. Luke’s Academy and any of their officers, staff members or agents from lawsuit, claim, demand, or action against them for adminstrating prescribed medication to this student. Provided that St. Luke’s Academy staff are following the authorised prescriber’s order as written in Part II below. I have read the procedures outlined on this form and assumes the responsibilities as required.