Form Jhcd-R-F(1) - Release For Student To Carry Prescribed Inhaler Or Emergency Medication 2006
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1MESA PUBLIC SCHOOLS
Release for Student to Carry Prescribed Inhaler or Emergency Medication
Student Name ________________________________________________ Class / ID # _______________________
School / Year ________________________________________________ Date _____________________________
As the parent/guardian, I give permission for my child to carry and use a labeled inhaler or emergency medication as
prescribed by our health care provider.
Name of Medication ______________________________________________________________________________
Name of Medical Provider _________________________________________________________________________
Parent/Guardian Signature _________________________________________________________________________
Signature of Student (Jr/High School) ________________________________________________________________
Note: If the student demonstrates irresponsibility in carrying the medication, permission to carry may be withdrawn by
the school nurse. Medication must not be distributed to another student at any time. The parent/guardian assumes all
liability related to loss or misuse of this medication. A student who violates this policy will be subject to disciplinary
action.
School Nurse Signature _________________________________________
Date _________________________
JHCD-R-F(7) (Effective 01/24/06)
------------------------------------------------------------------------------------------------------------------------------------------------
MESA PUBLIC SCHOOLS
Release for Student to Carry Prescribed Inhaler or Emergency Medication
Student Name ________________________________________________ Class / ID # _______________________
School / Year ________________________________________________ Date _____________________________
As the parent/guardian, I give permission for my child to carry and use a labeled inhaler or emergency medication as
prescribed by our health care provider.
Name of Medication ______________________________________________________________________________
Name of Medical Provider _________________________________________________________________________
Parent/Guardian Signature _________________________________________________________________________
Signature of Student (Jr/High School) ________________________________________________________________
Note: If the student demonstrates irresponsibility in carrying the medication, permission to carry may be withdrawn by
the school nurse. Medication must not be distributed to another student at any time. The parent/guardian assumes all
liability related to loss or misuse of this medication. A student who violates this policy will be subject to disciplinary
action.
School Nurse Signature _________________________________________
Date _________________________
JHCD-R-F(7) (Effective 01/24/06)
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Parent category: Medical