Office of Evangelization and Catechesis
Roman Catholic Diocese of Albany

SELF-DIRECTED MEDICATION PERMISSION FORM

,  the parent or legal guardian of authorize the designation of

(Name of child/youth)

specified parish personnel of (click  one) St. Edward the Confessor or St. Mary's of Crescent  Parish who are notlicensed
 health care professionals, to supervise the administration of required medication, which is to be "self-directed" to my child.

Type of Medication             

Dosage and Frequency of Administration


Beginning date  //       Ending date  //   
                                  (month)      (day)          (year)                                             (month)     (day)           (year)

I understand that every effort will be made to notify me immediately should it become necessary to obtain emergency medical treatment
in connection with my child's condition.  The person(s) who should be notified and the telephone number(s) are:

NAME   Phone Numbers:  (home)(cell)

NAME   Phone Numbers:  (home)(cell)

In consideration of the acceptance of this authorization for the designation of the assistance for my child, I hereby, for myself, my heirs,
executors, administrators and assigns, waive and release any and all claims for damages I may have against said parish,
their representatives, employees, successors and assigns, rising out of any and all injured sustained.

Date ______ /____ /_____

Signature ____________________________________________

(Parent/Legal Guardian)