506.5E2 Parental Authorization and Release Form for the Self-Administration of Asthma Inhalers and Airway Medications

I authorize my child, _________________________, to self-administer his/her own asthma inhaler or airway medication at school. I agree that my child meets the requirement outlined in the District’s policy for the administration of his/her own asthma inhaler or airway medication at school.

I understand that the Spirit Lake 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 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                                                              Student’s Name

In this dosage:_________________________________________________________.

Dosage and Instructions (Frequency of Use)

For the purpose of:______________________________________________________.

________________________________________________ ________________.

Doctor's Signature                                                                          Date

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Approved: 3/10/03                                           Reviewed:  6/10/19                            Revised: 12/14/09; 5/13/13