7:270-E3 – Student Agreement to Carry and Self-administer Medication at School or School Activities
7:270-E3 – Student Agreement to Carry and Self-administer an epinephrine auto-injector (EpiPen®) and/or medication prescribed for asthma at School or School Activities
Student Name: _________________________________ Date: ________________
Student’s School: ____________________________________
Medication: ___________________________________ Order Date: ___________
Physician/prescriber: _________________________________
As the above named student, my signature indicates my agreement while I am at school or school activities to the following:
- I have demonstrated the correct administration of the above listed medication to the School nurse.
- I agree to never share my medication with another person.
- I agree to take my medication only in accordance with the prescribed dosage instructions.
- I agree if there are any problems or lack of desired effects in or after use of the medication I will notify a school staff member for assistance. I will not proceed to the nurse with an escort. Parents should be notified of medication use through the school health office
Student’s signature _____________________________ Date: __________________
Student Agreement to Carry and Self-administer an epinephrine auto-injector (EpiPen®) and/or medication prescribed for asthma at School or School Activities
Student Name: _________________________________ Date: ________________
Student’s School: ____________________________________
Medication: ___________________________________ Order Date: ___________
Physician/prescriber: _________________________________
As the above named student, my signature indicates my agreement while I am at school or school activities to the following:
- I have demonstrated the correct administration of the above listed medication to the School Nurse.
- I agree to never share my medication with another person.
- I agree to take my medication in accordance with the prescribed dosage instructions.
- I agree if there are any problems or lack of desired effects in or after use of the medication, I will notify a school staff member for assistance. I will not proceed to the nurse without an escort. Parents should be notified of medication used through the school health office.
Student’s signature_____________________________ Date _____________________
Date Approved: 03/05/2011
Date Amended: 08/30/2016
