Administration

Asthma Inhaler Request Form

In accordance with Illinois Public Act 92-402 and District 214 Medication Policy students may self-administer asthma medication at school. The completed form should be in the health office and needs to be renewed yearly. Each student should carry his/her own inhaler in its original pharmacy labeled container. It should be clearly labeled with:

1. Student's name
2. Drug name and exact dosage
3. Time medication is to be taken

I request that my student be allowed to carry his/her asthma medication and
self-administer as needed.

I hereby release H.S. District 214, its employees, agents and administration, from any and all liability as a result of injury arising from self-administration of medication by a student.

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Parent's Signature

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Date

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Student's Name

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I.D. Number

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Diagnosis

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Any Activity Restrictions - Explain

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Prescription Medication

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Dosage and Frequency

I certify that the student listed above has been instructed in the use of self-administration of his/her asthma medication. He/she understands the need for the medication, and the necessity to report to school personnel any unusual side effects. He/she is capable of using this medication independently.


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Physician Signature

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Physician Phone Number

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Date

Download pdf version of the Asthma Inhaler Form

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