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Self-Administer Medication Permission Form: (Auto-Injectable Epinephrine And/or Rapid-Acting Bronchial Inhalers ONLY)

This self-administration permission form allows a student to carry and self-administer auto-injectable epinephrine and/or rapid-acting bronchial inhalers at school. The form must be signed by the student's healthcare provider to confirm the health condition being treated and the approved medications. The student, parent, and school nurse must also sign to accept responsibility for the student self-administering the medication as prescribed and in accordance with the rules listed on the form.

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Wirley Valdez
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38 views1 page

Self-Administer Medication Permission Form: (Auto-Injectable Epinephrine And/or Rapid-Acting Bronchial Inhalers ONLY)

This self-administration permission form allows a student to carry and self-administer auto-injectable epinephrine and/or rapid-acting bronchial inhalers at school. The form must be signed by the student's healthcare provider to confirm the health condition being treated and the approved medications. The student, parent, and school nurse must also sign to accept responsibility for the student self-administering the medication as prescribed and in accordance with the rules listed on the form.

Uploaded by

Wirley Valdez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Self-Administer Medication Permission Form

(Auto-injectable epinephrine and/or rapid-acting bronchial inhalers ONLY)

Student: _____________________________________ Date: ______________

This letter confirms that the above-named student is a current patient and is
being treated for (i.e., health condition): ________________________________
________________________________________________________________

I agree that the student is responsible and capable of self-administration of the


following medications at school (please check those that apply):

_____ Rapid-acting bronchial inhaler (please include name, dose, and


frequency of the medication: _______________________________________

_____ Auto-injectable epinephrine (please include name, dose, and


frequency of the medication: _______________________________________

**The medications must remain in their original container(s) with the prescribing
information intact.

Healthcare Provider Signature: _______________________________________

I, the parent/guardian of __________________________ agree that my child is


responsible and capable of self-administration of the above medication(s). I
accept full responsibility and liability for my child carrying and self-administering
this medication(s).

Parent/Guardian Signature: ___________________________ Date: __________

I, _____________________ (student) agree that I am being given permission by


my healthcare provider, my parent(s)/guardian, and my school to carry and take
my own above-named medication(s) as needed. I will keep the permitted
medication in my book bag/locker. I will not share with or give my medication to
anyone. I will not take my medication for any reason except as prescribed. I
understand that my parent(s) and I accept full responsibility for my carrying and
taking my own medication as prescribed above. I understand that I will lose the
privilege of carrying the medication if I misuse it or do not adhere to the above
rules.

Student Signature: __________________________________ Date: _________

School Nurse Signature: ______________________________Date: _________

This form must be renewed each school year.

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