Policy 5141.21

Laurel Springs School

623 Grand Avenue

Laurel Springs, NJ 08021

  SELF-ADMINISTRATION OF MEDICATION FOR

STUDENTS WITH ASTHMA OR

 OTHER POTENTIALLY LIFE-THREATENING ILLNESS

Physician’s Written Order for Self-Administered Medication

(Page 1 of 2)

 I authorize that ____________________________________________ who suffers from

                                                      (student’s name)

________________________________________________________________________

                              (Asthma or other potentially life-threatening illness)

Be permitted to self-medicate with ___________________________________________

                                                                              (name of medication)

 _____________________________                           _____________________________

               (dosage)                                                                                  (time)

I further authorize that this student has been trained and is proficient in self-administration of the prescribed medication.

 The parent(s)/physician should be contacted under the following circumstances pertaining to this medication and/or illness:

______________________________________________________________________________

(Physician’s Signature)                                                           (Phone #)                              (Date)

(Parent/Guardian Signature)                               (Phone #                               (Date)

Note:  Physician’s authorization must be renewed each school year.

Policy 5141.21

 SELF-ADMINISTRATION OF MEDICATION FOR

STUDENTS WITH ASTHMA OR

 OTHER POTENTIALLY LIFE-THREATENING ILLNESS

 Physician’s Written Order for Self-Administered Medication

(Page 2 of 2)

                                                                                                                        (Date)_________________________________

Dear Parent:

 The Laurel Springs Board of Education has developed a policy whereby students with asthma or other potentially life-threatening illness may self-administer medication as prescribed by your family physician.

 Please be advised that the School District and its employees/agents shall incur no liability as a result of any injury arising from the self-administration of said medication by:  _______________________________________________(student).  Parent(s)/guardian(s) shall indemnify and hold harmless the District and its employees/agents against any claims arising out of self-administration of medication by the pupil.

 Please sign below, indicating that you have read and understand the above Release of Liability.

                                                                          ___________________________________

                                                                        Signature of Parent(s)/Guardian(s)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Parent(s)Guardian(s) Permission for Self-Administered Medication

                                                                                                                                                                                                                        Date________________________

I give permission for _____________________________________ to self-administer

(student’s name)

___________________________________ according to Dr. ____________________________

             (name of medication)                                                               (Physician’s name)

                                                                                 ___________________________________

                                                                                    (Signature of Parent/Guardian)

 Note:  Release of Liability and Parent Permission must be renewed each schoolyear.