Authorization for Administration of
Medication at School
Name of Student: _____________________________ Birth Date:
____________________
School: ________________________________________ Grade: ________________________
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Asthma Medication |
Dosage/Method i.e. pills, inhaler, spray |
Frequency |
Possible Side
Effects |
Comments |
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1. |
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2. |
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3. |
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Other
Considerations / Directions: _______________________________________________
School Year Start Date:
_________________ School Year Stop Date:___________________
(All authorizations expire at the end of the school year)
o Student is knowledgeable about the medication and
how to administer it.
o Student has the skills to safely possess and use an
inhaler.
o Student may self-administer the asthma medication.
Print Name of
Physician
Physician Signature
Clinic Address
Phone Number Date
Parent
/ Guardian Authorization
I request
that the above medication(s) be given during school hours as ordered by this
student’s physician / licensed prescriber. I also request the medication(s) be
given on field trips or other school sponsored activities, as prescribed.
I release
school personnel from liability in the event adverse reactions result from
taking the medication(s). I will notify the school of any change in the
medication(s) ( ex: dosage change, medication is discontinued, etc.).
I give permission for the school nurse to
communicate with the student’s teachers about the student’s asthma.
I give permission for the school nurse to consult with the above named
student’s physician / licensed prescriber regarding any questions that arise with
regard to the listed medication(s).
o My son/daughter may self-administer
his/her asthma medication (s).
Parent/Guardian Name Signature Date
NOTE:
Medication is to be supplied in the original / prescription bottle.
Ft.
Worth, TX 76102 817-297-3132
* 888-933-AAFA Serving
Dallas-Ft. Worth and all of Texas For
questions about asthma and allergies, contact AAFA-NTX
