Permission for Self-Administration

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_____ Follow the doctor's orders for taking and/or using this medication. _____ Not allow anyone else to use my medication. _____ Label my medication with ...

USD 378 - Riley County Schools Permission for Self-Administration of Anaphylaxis or Asthma Medication Name of Student_______________________________________________________ Grade___________ Medication_______________________________________________________ Purpose______________ Dosage_______________________________________________________ Time___________________ Conditions &Special circumstances for use__________________________________________________ Possible Side Effects____________________________________________________________________ Length of time medication is be administered________________________________________________ ____________________________________________________________ Physician’s Signature

___________________ Date

My child____________________________________________ has been instructed on selfadministration of the medication named and has my permission to administer the above named medication at school as ordered. I understand that it is my responsibility to furnish this medication. I acknowledge that the school incurs no liability for any injury resulting from the self-administration of medication and agree to indemnify and hold the school and it employees and agents harmless against any claims relating to the self-administration of such medication. ____________________________________________________________ Parent/Guardian Signature

___________________ Date

I accept the responsibility of carrying and administering my own (mark correct medication) _____Inhaler



This means I will:

_____ Have the medication with me at all times _____ Follow the doctor’s orders for taking and/or using this medication _____ Not allow anyone else to use my medication _____ Label my medication with my full name and the name of the medication.

____________________________________________________________ Signature of Student

___________________ Date

Note: the school district medication policy complies with state regulations. Self-Administration Medication DOES NOT include Over-the-Counter Medications or other prescription medications such as Ritalin, Adderall, Antibiotics, etc. Self-Administration Medication forms are to be kept on file in school office and must be renewed at the beginning of each school year medication is needed. Update 3/2019

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Name of medication: Reason for medication: Form of medication/treatment: Tablet/capsule. Liquid. Inhaler Injection. Nebulizer. Other. Instructions (Schedule and dose to be given at school):. Start: Date form received. Other, as specified: Stop: End o