Self -Administration Of Asthma Medication Form printable pdf download

SELF –ADMINISTRATION OF ASTHMA MEDICATION FORM

Pursuant to the School Code, the Sandoval School District will permit self-administration of medication by a

student with asthma. Complete this form if you have a son/daughter that has been diagnosed with asthma.

PARENT/GUARDIAN AGREEMENT FOR STUDENT TO CARRY ASTHMA MEDICATIONS AT

SANDOVAL SCHOOL DISTRICT SCHOOLS

I, _______________________________, being the parent/guardian of _________________________________

authorize the Sandoval School District to permit the above named student to self-administer his/her own

asthma medication. I will notify the school of changes in medication or my child’s condition.

Parent/Guardian Signature: _____________________________________ Date: __________________________

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PHYSICIAN REQUEST FOR SELF-ADMINISTRATION OF ASTHMA MEDICATIONS

Student Name: ______________________________________________ Birthdate: _______________________

The above named pupil has ____________________________________________________________________

(Name of Disease or Syndrome)

I am requesting that the above named student take the following medication(s) during school hours:

_____________________________________

________________________________

_____________________________________

________________________________

Name of Medication(s)

(Tablet, Liquid, Capsule, Inhaler)

_____________________________________

________________________________

_____________________________________

________________________________

Dosage

Dosage Time(s)

Possible Side Effects: _________________________________________________________________________

I certify that ___________________________________ has been instructed in the use and self-administration

of ______________________________________ (name of medication).

He/she understands the need for the medication, and the necessity to report to school personnel any unusual

side effects. He/she is capable of using this medication independently. I may be reached at the following phone

number in the event of a reaction to the medication or an emergency:

_____________________________________

_______________________________________

Phone Number of Physician

Signature of Physician

Date

_____________________________________

_______________________________________

Address of Physician

Print Name of Physician

Date

Self -Administration Of Asthma Medication Form