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__________________________________________________________________________________________ Note: This is to be filled out only if a child is bringing medication to program.

I hereby authorize and instruct ______________________________or another trained staff/volunteer to
administer medication identified above and supplied by me to ____________________, with a date of birth of
____________ (the “Child”), for the purpose of:
(a) providing temporary emergency response to a perceived life-threatening occurrence which may be seen to
result from an allergic or asthma reaction, the symptoms of which are:
(b) regular, prescribed dosages of medication sealed in an envelope provided with a completed label
OTHER SPECIAL INSTRUCTIONS (refer to pharmacist’s instructions):
Side effects: Stop medication if the following reaction(s) occur_______________________________
Storage required for medication:__________________________________________________
My signature shall be your good and sufficient authority to administer the medication (in the case of
Benadryl or Epipen injection through pre-measured liquid) and I shall not hold the medication
administrator, The Corporation of the City of Kitchener, any related Neighbourhood Association, their
employees, volunteers, personnel or agents (collectively, “Medication Administrator”) liable for any action
whatsoever which may arise out of the said medication administration, either at this given time or at any
given time in the future.

It is my responsibility to bring and pick up the medication and to ensure it is properly labeled with the Child's name
and the name of the drug and to confirm that the drug is not expired.
The Medication Administrator will attempt to have a trained person available or on-site, however, if advised that
the Medication Administrator is unable to do so, it is my responsibility to make alternative arrangements.
I HEREBY ACKNOWLEDGE that while reasonable precautions are taken by the Medication Administrator to
prevent accidents or other adverse occurrences, and in consideration of the Medication Administrator agreeing to
allow the Child to attend the playground program, I hereby indemnify, release and hold harmless the Medication
Administrator from any and all actions, causes of action, claims and demands for damages, loss or injury
howsoever arising out of or in any way attributable to the Child’s attendance at the program/event and the medical
condition, including without limitation, the administration of the medication and injuries or damages to third parties
or property.
I give permission to staff to take a photograph of the Child for identification purpose for staff. I am also aware that
from time to time the program/event may go or occur where there might not be a phone readily accessible (e.g., to
local parks and facilities) but staff will be carrying the Child's medication.
DATED at ___________________________ this ________ day of __________________, 2012
Signature of Authorizing Parent/Guardian


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