Jerome Joint School District No. 261

STUDENTS 3510F2

Indemnification/Hold Harmless Agreement

For Self-Administration of Medication

Student Name: ____________________________________________

The parent(s)/guardians(s) agree to indemnify, defend, and hold the school district harmless from any and all claims, actions, costs, expenses, damages and liabilities, including attorney’s fees, arising out of, connected with or resulting from the self-administration of medication by the student. The parent(s)/guardians(s) agree(s) that the school district, Board of Education, Board of Education employees and its agents shall incur no liability as a result of any injury arising out of or connected with the self-administration of medication by the student Specifically, the

parent(s)/guardian(s) agree that they will not institute either on their own behalf or on behalf of the student, any

claim or action against the Board of Education, Board of Education employees and its agents arising out of or

connected with self-administration of medication by the student.

This agreement shall take effect on the date listed below and shall stay in effect for as long as the student is provided permission to self-administer medication. This agreement must be signed and in full effect prior to the granting of permission to self-administer medication.

___________________________________________ ______________________________________________

Parent/Guardian’s Name (Please Print) Parent/Guardian’s Signature

___________________________________________ ______________________________________________

Parent/Guardian’s Name (Please Print) Parent/Guardian’s Signature

___________________________________________ ______________________________________________

Principal’s Signature Date of Agreement

Policy History:

Adopted on: 04/28/2009

Revised on: 02/24/2015