Inhaler Release Form printable pdf download

MONONA GROVE SCHOOL DISTRICT ~ INHALER RELEASE FORM

Monona Grove High School

Glacial Drumlin School (gr. 5-8)

Cottage Grove School (gr.2-4)

4400 Monona Dr, Monona, WI 53716

807 Damascus Tr. Cottage Grove, WI. 53527

470 N. Main St, Cottage Grove, WI 53527

608-221-7666 fax: 608-221-7690

608-839-8437 Fax: 608-839-8984

608-839-4576 fax: 608-839-4439

Winnequah School (gr. EC, 4K-5)

Taylor Prairie School (EC, 4K-1)

800 Greenway Rd. Monona, WI. 53716

900 N Parkview St, Cottage Grove, WI 53527

608-221-7677 fax: 608-223-6514

608-839-8515 fax: 608-839-8323

Date_________________________

Birth Date: ____/____/____

Grade____________________

Student’s Name ____________________________________________________________________________________

FOR COMPLETION BY PHYSICIAN

Physician’s Name: _________________________________________________________________________________

Telephone Number: ______________________________________ Fax Number: ______________________________

Emergency Contact Number: ________________________________________________________________________

Diagnosis: _______________________________________________________________________________________

Name of Medicine: ________________________________________________________________________________

Form: _____________________________________________ Dose: _______________________________________

Is the child knowledgeable about his/her asthma medication?

Yes

Has the Child demonstrated the proper technique in administering medication?

Yes

Medicine is administered daily ___________________________________

Yes

Medicine is administered when needed. Indications: ______________________________________________________

_________________________________________________________________________________________________

If needed, how soon can administration of medicine be repeated? ____________________________________________

The medication can not be repeated more than___________________________________________________________

Side effects: ______________________________________________________________________________________

Comments: ______________________________________________________________________________________

Please check all that apply:

I have instructed the above named student in the proper way to use his/her inhaled asthma medications. It is my

professional opinion that he/she should be allowed to carry and use this inhaled medication by him/herself.

It is my professional opinion that the above named student should not carry and use his/her inhaled asthma medication

by him/herself. If this box is checked, I authorize school staff to administer the medication named above and understand

that the inhaler will be kept in the school office and will be packed in a backpack to be taken on field trips.

________________________________________________

__________________

Physician’s Signature

Fax Number

Phone Number

FOR COMPLETION BY PARENT

We, the parent/guardian of the above named student, request that assistance be provided to my child in taking the

medicine(s) indicated above at school by authorized staff. If self-medicating is allowed or if no authorized staff member is

available, I ask that my child be permitted to self-medicate as authorized by my physician and myself. Authorization is

hereby granted to release this information to appropriate school personnel and classroom teachers.

We, the parent/guardian of the above named student authorize permission for him/her to carry the inhaler on his/her

person or keep same in his/her locker or desk, as we consider him/her responsible. He/she has been instructed in and

understands the purpose and appropriate method and frequency of use of his/her inhaler.

Yes

The school office has been provided with a back-up inhaler:

Yes

Parent/Guardian Name: _________________________________________________________

Parent/Guardian Signature: _______________________________________________________

Work Phone: _____________________Home Phone: ____________________

Revised 5/2010 LH form available at

Inhaler Release Form

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