PERMISSION FOR SELF-ADMINISTRATION OF MEDICATIONS
FOR POTENTIALLY LIFE-THREATENING ILLNESS
NAME _____________________________________ DATE ________________
MEDICATION ______________________________ DOSAGE _____________
GUIDELINES FOR ADMINISTRATION _______________________________
(Please be specific)
__________________________________________________________________
__________________________________________________________________
I certify that _____________________ suffers from a potentially life-threatening
illness
____________________ and is capable of, and has been instructed in the proper
method of self-administration of the above stated medication.
______________________ _______________________ ____________________
Physician’s Printed Name |
Date |
Physician’s Signature |
To be completed by the Parent/Guardian:
I
acknowledge that the Board of Education shall incur no liability as a result of
any injury
arising from the self-administration of medication by my child. I shall
indemnify and hold harmless
the district and its employees or agent against any
claims arising out of the self-administration of
medication by my child.
I give permission for ___________________________ to self-administer __________________________ as prescribed by his/her private physician.
_______________________ _______________________ ____________
Parent/Guardian Name Parent/Guardian Signature Date
This permission form is effective
for the school year for which it is granted and must be renewed
each school year.
MUST COMPLETE “ASTHMA ACTION PLAN” FOR
ASTHMA
DIAGNOSIS – ASTHMA ACTION PLAN ON REVERSE SIDE.
Sincerely,
Mrs. Lynch
Mrs. Kelly Lynch, R.N., B.S.N.
Certified School Nurse/Health Teacher