You are here

Code No. 507.2E2 Parental Authorization and Release Form for the Self-Administration of Asthma Medication to Students

I authorize my child, _________________________, to self-administer his/her own asthma inhaler or airway medication at school. I understand that the Interstate 35 Community School District and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from my child's self-administration of medication. The school district, and its employees, acting reasonably and in good faith, shall incur no liability for any improper use of medication, or for supervising, monitoring, or interfering with a student's self-administration of medication.

______________________________________________________________________

Parent or Guardian Signature                                                                              Date

----------------------------------------------------------------------------------------------------------

The Following to Be Completed by the Student’s Physician:

I have prescribed the following medication (asthma inhaler/airway medication)

______________________________for this student____________________________

Name of Medication                                                                           Students Name

In this dosage:_________________________________________________________.

Dosage and Instructions (Frequency of Use)

For the purpose of:______________________________________________________.

________________________________________________           ________________.

Doctor's Signature                                                                                          Date

 

Revised/Reviewed: February 25, 2019