Patent or Guardian Daytime Telephone Date. If student is taking more than one medication at school, list sequence in whi
INHALER AUTHORIZATION SPOTSYLVANIA COUNTY SCHOOLS PART I
PLEASE READ PARENT INFORMATION ABOUT INHALERS
PARENT OR GUARDIAN TO COMPLETE
I hereby request Spotsylvania County Schools to permit the student identified below to use an inhaler in school as soon as an asthmatic attack begins. I agree to release, indemnify, and hold harmless Spotsylvania County Schools and any of their officers, staff members, or agents from lawsuits, claim, expense, demand, or action, etc., against them for assisting this student with the inhaler, provided Spotsylvania County Schools and personnel are following physician orders as written in
□ Renewal
Medication:
□ New (If new, the first full does must be given at home to assure that the student does not have a negative reaction; first doasage was given ________________________________________.)
Student Name: (Last, First, Middle)
Date of Birth
School
_____________________________________
________________________________
Patent or Guardian PART II
__________________
Daytime Telephone
Date
PHYSICIAN TO COMPLETE
DIAGNOSIS: DATE OF ORDER:
MEDICATION: (TRADE NAME)
DURATION OF ORDER: (NOT TO EXCEED CURRENT SCHOOL YEAR)
TIME INTERVAL FOR REPEATING DOSAGE:
DOSAGE AT SCHOOL
TIME(S) MEDICATION IS GIVEN:
SYMPTOMS OR CONDITIONS FOR WHICH MEDICATION IS ORDERED:
If student is taking more than one medication at school, list sequence in which medications are to be taken:
Check appropriate box: I believe that this student has received adequate information on how and when to use an inhaler and that he or she can use it properly.
□ □
The student is to carry an inhaler during school hours. The inhaler will be kept in the school clinic or other approved location (specify): _________________
________________________________ Physician’s Name (Print or Type)
________________________________________ Parent Signature (Required if student carries inhaler) PART III
_____________________ Telephone/fax
_________________________________________ Student Signature (Required is student carries inhaler)
_____________ Date
_____________________ Date
PRINCIPAL OR PRINCIPAL DESIGNEE TO COMPLETE
Check as appropriate:
□ □ □
Parts I and II above are completed including signatures. Medication is appropriately labeled. The student has been approved by the principal to carry an inhaler. A student health care plan, signed by the parent and physician, is on file.
_________________________________________________________ Principal or Principal Designee Signature
________________________ Date
Information from the Spotsylvania County Schools student scholastic record is released on the condition that the recipient agrees not to permit any other party to have access to such information without the written consent of the parent or of the eligible student.
