Authorization for Student Self-Carry and Administration of Medication (Inhaler) for at School & After School Activities

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REQUIRES PHYSICIAN TO COMPLETE WITH PHYSICIAN'S SIGNATURE (PHYSICIAN SECTION).

Applicable to 6-8th Grade Students Only

Per Concordia's policy, 6-8th students may self-carry with completion of this form and the physician's approval. Administration/staff will reserve the right to request a student medication administration be supervised, even if student administers own medication at home.

CONCORDIA LUTHERAN ELEMENTARY SCHOOL

4245 Lake Avenue
Fort Wayne, IN 46815
Phone: (260) 426-9922 x200
Fax (260)422-6980
Michelle Horn, RN
Email: shorn@clscubs.org

Student's Name

Student's Date of Birth

Student's Grade

Medication Name:

Dosage:

Time to be Taken

Time

Physician's Name & Phone #

Physician

Physician, please check any statements listed below that you support

Student has received training in the proper use of the inhaler

Student demonstrates the proper technique while using the inhaler

I request that the student carry and self-administer the above named medication during the school hours and at school activities

The parent/legal guardian will supply additional inhaler to be kept in the school office in case the child fails to have the inhaler with him/her

In my opinion, this student is capable to carry and self-administer the medication listed above

Physician's Office

Please print completed form to send with parent to return to school, fax to school at 260-422-6980, or email to Michelle Horn, RN at shorn@clscubs.org.

Physician's Signature

YYYY

I understand that this electronic signature below provides the same legal standing as a handwritten signature

Student's Signature

YYYY

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