Office of the Superintendent of Schools
To: Parents/Guardians
Date: September 2005
Subject: Permission to Self-Administer
Inhaler/Medication for Life Threatening Illness in School
A pupil may be permitted to self-administer an inhaler or medication for a life threatening illness in school or during a school-sponsored field trip under the following conditions:
Ÿ
The child’s physician must certify, in writing, that the child has
asthma or another life threatening illness and that the child is capable of and
has been instructed in the proper administration of the required medication.
Ÿ
The parent must understand that the school district will not accept any
responsibility for injury arising from the self-medication and sign the
following statement to that effect.
Ÿ
Permission is effective for the school year for which it is granted and
must be renewed annually.
Name
of Medication _________________________________
Dosage ___________________
Purpose
of Medication ___________________________________________________________
Time
to be given ________________________________________________________________
Number
of days (a termination date) ________________________________________________
Possible
side effects _____________________________________________________________
Prescribing
physician’s name ___________________________ Phone # ___________________
(Print name clearly)
I
hereby give permission for my child to self-administer an inhaler/medication
for a life threatening illness. Attached
is the physician’s letter regarding the use of the inhaler/medication for life
threatening illness.
I understand that the school district will not be held responsible for
any injury arising from self medication.
Parent/Guardian
Name: _______________________
Signature: _________________________
(Print name clearly)
Date:
__________________
Telephone, Home:
_______________Work: ________________
1/5/2000,
9/2000, 9/05