Church of the Redeemer will not dispense prescription medication to a minor child or other participant until this Medication Consent & Waiver Form has been fully completed by a parent or guardian.
PERMISSION TO RELEASE & INSTRUCTIONS FOR RELEASE OF MEDICATION
I, the parent or guardian of the above-listed child, give permission to Church of the Redeemer, St. Paul, MN, to administer to my child the medication listed below.
I understand it is my responsibility to give the medication directly to the church staff or volunteers in individual dosage containers, original prescription containers, or envelopes clearly labeled with the following information:
PARTICIPANT'S NAME
NAME OF MEDICINE AND COMPLETE DOSAGE INSTRUCTIONS
In all cases the recommended dosage of any medication will not be exceeded. If after administering medication there is an adverse reaction, I give my permission to Church of the Redeemer to secure from any licensed hospital physician and/or medical personnel any treatment deemed necessary for immediate care. I agree to be responsible for payment of any and all medical services rendered.
WAIVER & RELEASE OF ALL CLAIMS
I recognize and acknowledge that there are certain risks of physical injury in connection with the administering of medication to my minor child. Such risks include, but are not limited to, failing to properly administer the medication, failing to observe side effects, failing to assess and/or recognize an adverse reaction, failing to assess and/or recognize a medical emergency, and failing to recognize the need to summon emergency medical services.
In consideration of Church of the Redeemer administering medication to my minor child, I do hereby fully release or discharge Church of the Redeemer and its officer, agents, volunteers, and employees from any and all claims from injuries, damages, and losses I or my minor child may have (or accrue to me or my minor child), and arising out of, connected with, incidental to, or in any way associated with the administering of medication.
By typing my full name and today's date below, I am verifying that the information supplied in this form is true to the best of my knowledge. I am further agreeing to the statements of waiver, release, and permission contained in this form.
