Caldwell-West Caldwell Public Schools

Self-Administered Inhaler Permission Form

A pupil may be permitted to self-administer an inhaler under the following conditions:

The child’s physician must clarify, in writing that the child has asthma or another life threatening illness and that the child is capable of and has been instructed in the proper administration of the required medication.

The parent must understand that the school district shall not accept any responsibility for injury arising from the self-administration and sign the following statement. 

The medication must be in the original prescription container, properly labeled.

Permission is effective for the school year in which it is granted and must be renewed annually.

Self-Administered Inhaler Permission Form

Student Name: ____________________________________ Grade: _______ School: _________

Name of Medication: ____________________________________________________________

Dosage: ___________________________________ Time to be given: ____________________

Number of days (termination date): _________________________________________________

Purpose of Medication: __________________________________________________________

Possible side effects: ____________________________________________________________

Prescribing physician’s name ________________________________ Phone: _______________

                                                            (Print name clearly)

Physician’s Signature____________________________________________________________

I hereby give permission for my child to self-administer an inhaler.  Attached is the physician’s letter regarding the use of the inhaler.  I accept full responsibility for my child’s use of the inhaler and will not hold the school district responsible for any injury arising from self-medication.

Signature: ________________________________________________ Date: _______________

Home phone: ________________________________ Business Phone: ____________________