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Aromas-San Juan USD |  E  5141.21  Students

Administering Medication And Monitoring Health Conditions   

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PARENTAL CONSENT FOR STUDENT TO CARRY AND SELF-ADMINISTER PRESCRIPTION INHALED ASTHMA MEDICATION AND/OR AUTO-INJECTABLE EPINEPHRINE

School Year 20____- 20____

I authorize the Aromas-San Juan Unified School District to permit the following student to carry and self-administer the medication(s) prescribed to him/her as indicated below.

Student Name (please print) Grade

Name of Medication Form Dosage

I consent to having the school nurse and other designated school personnel consult with the healthcare provider of the above named student regarding any questions that may arise with regard to the medication(s) indicated above.

I release the Aromas-San Juan Unified School District and school personnel from civil liability if the self-administering student suffers an adverse reaction by taking the medication(s) indicated above.

This consent form is valid for the current school year only. It is the responsibility of the parent/guardian to provide a signed consent form annually and more frequently if the medication, dosage, frequency of administration, or reason for administration changes.

I acknowledge that pursuant to Ed Code Section 48900 a pupil may be subject to disciplinary action if that pupil uses inhaled asthma medication and or uses auto-injectable epinephrine in a manner other than as prescribed.

If applicable, please discontinue this request as of the following date .

Parent/Guardian Full Name (please print)

Signature Date

Parent/Guardian Full Name (please print)

Signature Date

Note: Signatures of both parents or guardians are required if they are living with or have custody of the child.

Exhibit AROMAS-SAN JUAN UNIFIED SCHOOL DISTRICT

version: April 13, 2011 San Juan Bautista, California