I request that my child______________________________grade_______receive the medication as prescribed below by our licensed health care provider. The medication is to be furnished by me in the properly labeled original container from the pharmacy. I understand than the school nurse, or other designated person in the case of the absence of the school nurse, will administer the medication.
(Signature of Parent/Guardian)
Ph. Home _________ Work _________ Cell __________ Date:__________________
B. To be completed by the licensed health care provider
I request that my patient, as listed below, receive the following medication:
Name:_______________________________________ Date of Birth:_____________
Prescribed Frequency and Route of Administration:______________________________
Time During School Hours:_____________________________________________
Duration of Treatment: _______________________________________________
Side Effects Adverse Reactions (if any):___________________________________
Name Licensed Provider and Title (please print):___________________________________
Cattaraugus-Little Valley Intermediate School
207 Rock City Street
Little Valley New York 14755 Tele. 938-9155 Fax. 938-6576
Child’s Name:________________________________ has been instructed in the proper
use of the inhaler (name of)________________________________________________.
We, (Physician’s name) __________________________________________________
and (Parent/Guardian’s name) ______________________________________________
request that (Child’s name)_________________________________________________
be permitted to carry the inhaler on his/her person or to keep the same in his/her locker or P. E. Locker, as we consider him/her responsible. He/she has been instructed in and understands the purpose and appropriate method and frequency of use of his/her inhaler.
We, the undersigned, absolve the school of any responsibility in safeguard in our child’s use of the inhaler.
Note: The attached from must be completed in addition to the routine district medication form for those students who request permission to carry their own inhaler on campus or keep this inhaler in Physical Ed Locker.