Jerome Joint School District No. 261

STUDENTS 3510F1

AUTHORIZATION FOR SELF-ADMINISTERED ASTHMA/EMERGENCY MEDICATION

STUDENT’S NAME: _____________________________________ GRADE _______ DOB ____________________

PARENT/GUARDIAN NAME: _______________________________ TELEPHONE (HOME) ____________________

(WORK) ____________________

I give my permission for my child to self-administer the medication described below. I shall indemnify and hold

harmless the district and its employees or agents for legal fees, costs and any potential damages concerning self-

administration of this medication arising out of any claims brought by the above named child or anyone else.

________________________________________________________ _________________________________

Parent/Guardian’s Signature Date

THE FOLLOWING IS TO BE COMPLETED BY THE PHYSICIAN:

I am recommending that the above named student be allowed to self-administer the following medication.

Name and purpose of medication ____________________________________________________________

Identification of chronic medical problem ______________________________________________________

____________________________________________________________________________________________________

Prescribed dosage to be taken __________________________________________________________________

Length of time medication must be taken

Possible side effects and/or special precautions to be taken

Conditions under which self-medication will take place:

______ Independently Child must have had training and be proficient in self-administering medication.

Trainer’s Name: _____________________ Date of training: ________________________

______ Under the supervision of a school nurse

Medication should be _____ Stored in the health office

_____ In the possession of the student

_________________________________________ _________________________________________

Type or print physician’s name Physician’s Signature

_________________________________________

Policy History: Date

Adopted on: 04/28/2009

Revised on: 02/24/2015