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PART 1: PARENT OR LEGAL GUARDIAN TO COMPLETE.

PART 2: LICENSED PRESCRIBER TO COMPLETE.

Check Route:

Checkboxes

Duration of medication order:

Checkboxes

PART 3: LICENSED PRESCRIBER TO COMPLETE AS APPROPRIATE.

Inhalants / Emergency Drugs
Release Form for Students to be Allowed to Carry Medication on His/Her Person

Use this space only for students who will self-administer medication such as asthma inhaler.

Is the student a candidate for self-administration training?
Has this student been adequately instructed by you or your staff and demonstrated competence in selfadministration of medication to the degree that he/she may self-administer his/her medication at school, provided that the school nurse has determined it is safe and appropriate for this student in his/her particular school setting?
If training has not occurred, may the school nurse conduct a training program?