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