Self-Administration Of Asthma Inhaler/epinephrine Auto-Injector Permission Form printable pdf download

NORTHERN YORK COUNTY SCHOOL DISTRICT

SELF-ADMINISTRATION OF ASTHMA INHALER/EPINEPHRINE

AUTO-INJECTOR PERMISSION FORM

Name ____________________________ Name of Medication ________________________ Date __________

School ________________________________ Grade ________________ DOB

______________________

Criterion for student self-administration of Asthma Inhaler and/or Epinephrine Auto-Injector

The prescribed medication shall be maintained in a clearly labeled original container noting the child's name, the medication

name, and the time and/or special circumstances for self-administration.

Student is able to:

-Verbalize symptoms/situation related to the need for medication use.

-Demonstrate the correct technique for self-administration of the medication.

-Follow the emergency action plan as prescribed by physician.

-Inform the school nurse immediately after self-administering asthma inhaler or epinephrine auto-injector.

-Store medication in a secure location where it is easily accessible.

I will take responsibility for carrying and self-administration of my asthma inhaler and/or epinephrine auto-injector at school. I

have read and understand the school policy regarding self-administration and possession of this medication. If I violate this

school policy, I understand that it will result in loss of privilege to self-carry my medication as well as possible disciplinary

action in accordance with Board policy. I understand that in order for me to self-administer and carry my medication, I

must meet with the school nurse for final approval of this process.

STUDENT SIGNATURE __________________________________ Date ___________________

I certify that my son/daughter is able and responsible to carry and self-administer their asthma inhaler and/or epinephrine auto-

injector. I give permission for self-administration and possession of the ordered medication for my child to use during school

hours, at any time while on school property, at any school-sponsored activity, and during the time spent traveling to and from

school and school-sponsored activities. I understand and consent to the stipulations of the school policy regarding self-

administration of medication. I understand my child may lose this privilege if the policy is violated. I understand and agree that

in the event of an emergency, a district employee may administer emergency medication (e.g epinephrine, inhalers, etc.) when

s/he believes, in good faith, that a student needs emergency care. I also agree that the school entity bears no responsibility for

ensuring that the medication is taken. I understand that emergency medical services will always be notified when epinephrine

is administered, whether or not the student manifests any symptoms of anaphylaxis. I will inform the school nurse if there are

changes in this medication.

I hereby release, indemnify, and hold harmless the Northern York County School District, its employees, and its agents against

any claim(s) arising out of the administration or self-administration of medication pursuant to this permission form, or related

to the benefits or consequences of the prescribed medication. I understand this permission form must be completed by both

a physician and the school nurse prior to my child self-administering or carrying his/her emergency medication.

PARENT/GUARDIAN SIGNATURE _____________________________ Date _________________

It is my professional opinion that this student may carry and self-administer his/her medication according to the orders

prescribed on the attached emergency action plan.

PHYSICIAN SIGNATURE _______________________________________Date ___________

The student, ____________________has demonstrated competency for self-administration and responsible behavior in use

of the prescribed medication.

SCHOOL NURSE SIGNATURE _______________________________ Date _____________

This authorization is good for one school year and must be renewed each year.

{00759146.2 }

Self-Administration Of Asthma Inhaler/epinephrine Auto-Injector Permission Form