Rhyme & Reason Social Program

Authorization to Dispense Prescribed Medication

I request permission for the participant named in this form to receive the prescribed medication and treatment specified below during Rhyme & Reason sponsored events.

• It is the responsibility of the emancipated individual or the guardian of the individual to give the medication directly to the Rhyme & Reason staff in original prescription containers clearly labeled with the individual’s name and the dispensing information as indicated on the following page of this Form.
• In all cases, dispensing of prescribed medication can only be changed or modified by completing another Authorization to Dispense Prescribed Medication Form.
• Medical Treatment: In all cases, the recommended dosage of a medication will not be exceeded. If, after administering medication, there is an adverse reaction, I give my permission to Rhyme & Reason to secure any and all medical services necessary from any licensed hospital physician and medical personnel. Further, I hereby release and forever discharge Rhyme & Reason from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with a medical or psychiatric emergency during the foster child’s participation.
• I expressly agree that this authorization is intended to be as broad and inclusive as permitted by the laws of the State of Indiana and that this authorization will be governed by and interpreted in accordance with the laws of the State of Indiana. I agree that in the event that any clause or provision of this authorization is deemed invalid, the enforceability of the remaining provisions of this authorization will not be affected.

Waiver Form

By entering my name in the Digital Signature Field below, I acknowledge that I have read and understand this release.

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