Medication Self-Carry Authorization For Sports Or After School - Nursing Health Manual

Download a blank fillable Medication Self-Carry Authorization For Sports Or After School - Nursing Health Manual in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Medication Self-Carry Authorization For Sports Or After School - Nursing Health Manual with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Reset Form
Print Form
M
S
-C
A
S
A
S
EDICATION
ELF
ARRY
UTHORIZATION FOR
PORTS OR
FTER
CHOOL
S
__________________________ S
______________________
TUDENT
CHOOL
A
G
______________________
______________________________
CTIVITY
RADE
The Anchorage School District and Alaska law (AS 14.30.141) permit a responsible, trained student to carry
and/or self administer prescription labeled medication for Asthma, Anaphylaxis (severe allergic reaction),
or Diabetes on his/her person for immediate use in a life-threatening situation upon written order of
health care provider with prescriptive authority, parent request, and school nurse approval
.
P
S
ARENT
TATEMENT
As parent/guardian of _________________________________, I permit him/her to carry and self administer the
below ordered medication. I take responsibility for this permission and verify that my child has been trained in the
proper administration of this medication including when to take it, the appropriate dosage, how to manage the side
effects, what to do in an emergency. My child understands not to share this medication with anyone else. I
understand that the medication must be in the original pharmacy container, labeled with name of student,
prescribing health care provider, and medication; date of original prescription; strength and dose of medication; and
directions for use. I will notify the school immediately if the medication is changed and understand that the nurse
may contact the physician or pharmacist regarding this medication. I agree to defend and hold the school district
employees harmless from any liability for the results of the medication or the manner, in which it is administered,
and to defend and indemnify the school district and its employees and coaches for any liability arising out of these
arrangements.
Parent/Guardian Signature ________________________________________Date __________________
Home Phone ___________________________ Work/Emergency Phone__________________________
Other medications your child is taking
Student acknowledges the requirements __________________________________________
Student Signature
H
P
S
EALTHCARE
ROVIDER
TATEMENT
This medication is required during after school hours to improve or maintain the health of this student. The nurse
may contact me regarding this medication. This child should receive prescribed medication for the following
Condition_ __________________________________Medication__________________________________________
Dosage________________________ Time & Dosage during activity:_______________________________________
Side effects to be noted/reported ___________________________________________________________________
Other recommendations__________________________________________________________________________
Beginning Date _________________________________ Ending Date ______________________________________
I
,
-
.
N MY OPINION
THIS STUDENT SHOWS CAPABILITY TO CARRY AND SELF
ADMINISTER THE ABOVE MEDICATIONS
Healthcare Provider Signature__________________________________________ Date __________________
Print Name ___________________________________________ Phone number ________________________
Healthcare Provider Address
S
N
S
____________________________ D
_____________
A
D
CHOOL
URSE
IGNATURE
ATE
PPROVED
ENIED
Anchorage School District
Nursing Health Manual
NUR # 0527
Revised 5/2011
Page 1 of 1

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Medical Records Release And Authorization For Use Or Disclosure Of Protected Health Information Form Medical Records Release And Authorization For Use Or Disclosure Of Protected Health Information Form Business
Authorization For Use Or Disclosure Of Protected Health Information Authorization For Use Or Disclosure Of Protected Health Information Legal
Authorization For Use Or Disclosure Of Patient Health Information Form Authorization For Use Or Disclosure Of Patient Health Information Form Business
Authorization For Use Or Disclosure Of Patient Health Information Form Authorization For Use Or Disclosure Of Patient Health Information Form Business
Authorization For Use Or Disclosure Of Protected Health Information Authorization For Use Or Disclosure Of Protected Health Information Business
Authorization For Use Or Disclosure Of Patient Health Information Form Authorization For Use Or Disclosure Of Patient Health Information Form Business
Hipaa Privacy Authorization Form - Authorization For Use Or Disclosure Of Protected Health Information Hipaa Privacy Authorization Form - Authorization For Use Or Disclosure Of Protected Health Information Medical
Form Ns-9934 - Authorization For Use Or Disclosure Of Patient Health Information Form Ns-9934 - Authorization For Use Or Disclosure Of Patient Health Information Business
After School Program Health History Form After School Program Health History Form Medical
Medical Information Form - Camp Herrlich Before And After School Programs Medical Information Form - Camp Herrlich Before And After School Programs Business

Related Categories

Parent category: Business
Download
Go