Permission to Carry Asthma Medication

In School or to School Activities

Student: _______________________

Grade: _________

Start Date: _________________

End Date: _________

Medication: ____________________________________________________________
Dosage: ________________________________________________________________
***Student must report to the nurses office after taking their medication***
If symptoms persist the School Nurse is to: _________________________________________
____________________________________________________________________________.
Adverse Reactions Possible: _____________________________________________________
____________________________________________________________________________.

I feel this student has the knowledge and skills to self-administer the above medication.

_________________________________

_____________

Physicians Signature

Physicians #

_________________________________

_____________

Parents Signature

Parents #

Date: ____________

Date: _____________