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506.2.2.1.2.2P - Authorization for Student Possession and Self-Medication with Inhaler, EpiPen, Insulin, and/or Other Emergency Medication at School

506.2.2.1.2.2P - Authorization for Student Possession and Self-Medication with Inhaler, EpiPen, Insulin, and/or Other Emergency Medication at School

Adopted: February 1990
Revised: July 2024

Download 506.2.2.1.2.2P - Authorization for Student Possession and Self-Medication with Inhaler, EpiPen, Insulin, and/or Other Emergency Medication at School

Name of child                                                                                                             

 

School                                                                      School year                      

 

Physician’s Order for Student and Self-medication

 

Name of medication                                                                                                    

 

          Dosage                                                                                                             

 

          Time/frequency                                                                                                

 

Medical Condition/ICD-10 code                                                                                  

 

Possible side effects                                                                                                    

 

Estimated termination date                                                                                        

 

                                                                                                                                 

 

The student is knowledgeable about the medication noted above and how to self-administer the medication.

 

Signature                                                                           Date                                

                    physician

 

Address                                                                                                                      

 

Telephone number                                                   

 

                                                                                                                                 

 

As authorized by my child’s physician, I request that my child be allowed to carry and self-administer the prescribed medication noted above.  I understand my child must carry this medication at all times in school or he/she will lose the right to carry and

self-administer the medication at school.

 

Signature                                                                            Date                                                     parent or guardian