School Medication Authorization Form; Self-Administration Of Emergency Medications Template (Page 2 of 2) in pdf

School Medication Authorization Form; Self-Administration Of Emergency Medications Template Page 2

This side must also be completed if the student will need to carry an inhaler or EpiPen while at school.

SELF-ADMINISTRATION OF EMERGENCY MEDICATIONS

A. Parent’s Request and Authorization

_________________________ to

I, THE UNDERSIGNED, request and authorize my child

) while

self-administer his/her medication: inhaler auto-injectable epinephrine (EpiPen

school.

(Circle one or both as appropriate)

This authorization is given based on the following:

My child is capable of and has been instructed in the proper method of self-administration

of this medication.

I understand that my child shall be permitted to carry at all times his/her medication as long as

he/she does not endanger him/herself, or endanger other persons, and will not misuse

the medication.

I understand that if my child misuses or exceeds the prescribed dosage, or endangers others

with the medication, school employees or agents may confiscate the medication.

Parent/Guardian Signature: ____________________________________Date:_____________

I, THE UNDERSIGNED,

Understand that Centralia High School District 200, its employees or agents shall not incur any

liability as a result of any injury arising from the self-administration of the medication by

my child;

shall exempt from liability and hold harmless school employees or agents against any claims

arising out of the self-administration of medication by my child;

understand that this authorization shall be effective for this current school year and must

be renewed annually.

Parent/Guardian Signature:________________________________Date:_________________

B. Physician’s Certification

I, THE UNDERSIGNED, certify that _____________________________ has asthma,

(Student’s name)

anaphylaxis, or another related potentially life-threatening illness ___________________, and

(Specify)

he/she is capable of and has been instructed in the proper method of self-administration of

his/her own inhaler_____and/or____auto-injectable epinephrine (EpiPen) medication.

(Circle appropriate medication)

Physician’s

Name: ________________________________

Signature:___________________________

(Type/print)

Address:________________________________ Telephone:_____________ Date______

Reviewed/Accepted by _______________________ Date:____________________

Received by ALB, RN:________________________ Date:____________________

Inhaler and EpiPen Consent Form

School Medication Authorization Form; Self-Administration Of Emergency Medications Template Page 2