Parental Permission for Prescription Inhaler

STUDENT'S NAME: __________________________________  DOB: ________________

PARENT/GUARDIAN: ______________________________________________________

HOME PHONE: _______________________  WORK PHONE: ______________________

NAME OF INHALER: _______________________________________________________

PRESCRIBED BY: ___________________________________  PHONE: _____________

# OF INHALATIONS AND TIME INTERVALS _____________________________________

PLEASE CHECK ALL THAT APPLY:

_____          MY CHILD MUST CARRY INHALER AT ALL TIMES.

_____          MY CHILD DOES NOT NEED TO CARRY INHALER, IT SHOULD BE 
                          AVAILABLE IN HEALTH ROOM.

_____          INHALER SHOULD BE USED _____ MINUTES BEFORE EXERCISE.

OTHER HELPFUL INFORMATION CONCERNING YOUR CHILD'S ASTHMA: ____________

________________________________________________________________________

________________________________________________________________________

I understand that this medication must be furnished by me.  If the inhaler is to be with my child
at all times, I release the school from any responsibility concerning misplacement, theft, or
misuse of this medication.  I will notify the school immediately in writing if the medication has
been discontinued or dosage changed.

Parent's Signature: ______________________________  Date: _____________________

    
          ANY MEDICATION ON HAND AT THE END OF THE SCHOOL YEAR WILL BE
DESTROYED IF NOT PICKED UP BY A PARENT OR OTHER ADULT DESIGNATED BY THE PARENT.