_________________________________      ___/___/___      _________________        ___/___/___ 

Student's Name (Last), (First),  (Middle)          Birthday                School                               Date

I request the above-named student (Parent/Guardian initial all that apply)

______ Carry and complete co-administration of prescribed medication, when competency has been demonstrated to licensed health personnel working under the auspices of the school. In accordance with applicable laws, students with asthma, airway constricting diseases, respiratory distress or students at risk of anaphylaxis who use epinephrine auto-injectors may self-administer their medication upon the written approval of the student’s parents and prescribing licensed health care professional regardless of competency.  The information provided by the parent for medication administration is confidential as provided by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws.  I agree to provide safe delivery of the medication to and from school and to pick up remaining medication at the end of the school year or when medication is expired. If the students abuses the self-administration policy, the ability to self-administer may be withdrawn by the school or discipline may be imposed, after notification is provided to the student’s parent.

____________________________________________________________________________________

Prescribed Medication                       Dosage                     Route                   Time at School 

______ Co-administer, participate in planning, management and implementation of special health services at school and school activities after demonstration of proficiency to licensed health personnel working under the auspices of the school. The information provided by the parent for health service delivery is confidential as provide by the Family Education Rights and Privacy Act (FERPA) and any other applicable laws.  I agree to coordinate and work with school personnel and the prescriber (if indicated) when questions arise.  I agree to provide safe delivery of the student’s equipment necessary for health service delivery to and from school and to pick up remaining equipment at the end of the school year.

 Special Health Services Delivery: _________________________________________________________

Procedures for abandoned medication disposal shall be in accordance with applicable laws.

_________________________________________                    ______________________

Prescriber’s Signature                                                                                 Date

and credentials (when indicated for health service delivery)

__________________________________________                   ______________________                                                                                                            

Parent/Guardian Signature                                                                           Date 

_______________________________________                        __________________________

Parent/Guardian address                                                                         Home phone