Asthma Care Plan Template (2012) Page 2
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Asthma Care Plan for
Student Name ____________________________________
Individual Considerations
Field Trip Procedures
Rescue medication to accompany student during any off campus activities.
Staff members on trip must be trained regarding medication use and student health care plan (plan must be taken).
Other (specify):
Bus—Transportation should be alerted to student’s asthma.
This student carries Inhaler on the bus:
Yes
No
Inhaler can be found in:
Backpack
On person
Student will sit at front of the bus:
Yes
No
Other consideration:
EMERGENCY CONTACTS
1.
Relationship:
Day Phone:
Cell Phone:
2.
Relationship;
Day Phone:
Cell Phone:
3.
Relationship:
Day Phone:
Cell Phone:
4.
Relationship:
Day Phone:
Cell Phone:
I approve this Asthma Care Plan for my child.
I request this medication to be given as ordered by the Health Care Provider.
I give consent to share information about my child’s asthma with the district nurse, health assistant, teachers, principal,
office staff, guidance, bus driver/transportation, cafeteria workers, playground staff, and emergency staff on a “need to know basis”.
I give Health Services Staff permission to communicate with the medical office about this care plan / medication. I understand the
medication(s) will not necessarily be given by the district nurse, but may be given by the health assistant or designated trained staff.
Parent/guardian must provide medication/equipment required to administer medication or provide special medical care.
All medication supplied must come in its original pharmacy-labeled container; and the container specifies the student’s name,
name of prescriber, the name of medication, the dose, the effective date, and the directions for administration.
(Grades 7-12) I request and authorize my child to carry and/or self-administer their medication .
Yes
No
This permission to posses and self-administer an Inhaler may be revoked by the principal/district nurse if it is determined that
your child is not safely and effectively able to self-administer.
Any changes in medication require a new written authorization and corresponding change in the prescription label.
I understand that the medication maintained in the health room is not available after school hours, and that I need to provide
additional rescue medications for my child when involved in sports/activities after school hours.
Parent/Guardian Signature ___________________________________________________ Date _________________________
District Nurse Signature ________________________________________________________________ Date Reviewed ____________________
Fax Numbers:
Big Bend 262-662-1309
Clarendon 262-363-6289
Eagleville 262-594-5495
Prairie View 262-392-6312
Rolling Hills 262-363-6343
Section 262-363-6341
Park View 262-363-6320
Mukwonago High 262-363-6239
District Nurse Phone: 262-363-6292 x27515 Fax: 262-363-6320
Page 2 of 2
05/2012 by LAH
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