INHALER SELF-MEDICATION RELEASE FORM

Date _____________________________

Child’s Name __________________________________________________

Has been instructed in and understands the purpose, appropriate method and frequency of use for the following inhaler:

We, (Physician’s Signature) _________________________________________

And (Parent or Guardian) ___________________________________________

Request that he/she be permitted to carry the inhaler on his/her person and to keep same in his/her locker or P.E. locker, as we consider him/her responsible.

NOTE: This form must be completed in addition to the PERMISSION FOR PRESCRIPTION MEDICATION IN SCHOOL form on the reverse side.