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HS001 Rev 7/05 CHESAPEAKE PUBLIC SCHOOLS Request for Self-Administration of Emergency Medication Notice to Parents Medication must be brought to school by parent or legal guardian in a container that is appropriately labeled by the pharmacy or physician. Name of Student Last First MI Date of Birth Diagnosis Dosage Home Phone ----------------------------------------Parent Work Medication When should inhaler be used Frequency with which it is to be administered. Route of Administration and Instructions Start Date must be renewed yearly End Date Physician/Nurse Practitioner please print Address Phone Number In accordance with the Code of Virginia Section 22. 1-274. 2 by signing this form I attest to the student s demonstrated ability to safely and effectively self-administer inhaled asthma medications and/or auto-inject epinephrine and of the student s understanding that he is to report to the school nurse or if the school nurse is not available to the principal or his designee if self- administered medication as prescribed does not relieve the student s asthmatic/allergic symptoms. I further agree to prepare a written individual health care plan in consultation with the student s parents and appropriate school personnel* I hereby give permission for the school to administer the medication as prescribed above. I also give permission for the school to contact the above health care provider regarding the administration of this medication and the development of a health care plan* I will not hold the school board or any of its employees liable for any negative outcomes resulting from the selfadministration of said emergency medication by the student. I understand that the school principal after consultation with the parent s may impose reasonable limitations or restrictions upon a student s possession and self-administration of said emergency medication relative to the age and maturity of the student or to other relevant considerations. at any point during the school year if it is determined the student has abused the privilege of possession and selfadministration or that student is not safely and effectively self-administering the medication* Parent s/Legal Guardian s Signature Date. 1-274. 2 by signing this form I attest to the student s demonstrated ability to safely and effectively self-administer inhaled asthma medications and/or auto-inject epinephrine and of the student s understanding that he is to report to the school nurse or if the school nurse is not available to the principal or his designee if self- administered medication as prescribed does not relieve the student s asthmatic/allergic symptoms. I further agree to prepare a written individual health care plan in consultation with the student s parents and appropriate school personnel* I hereby give permission for the school to administer the medication as prescribed above. I further agree to prepare a written individual health care plan in consultation with the student s parents and appropriate school personnel* I hereby give permission for the school to administer the medication as prescribed above. I also give permission for the school to contact the above health care provider regarding the administration of this medication and the development of a health care plan* I will not hold the school board or any of its employees liable for any negative outcomes resulting from the selfadministration of said emergency medication by the student.

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