Inhaled Medication Authorization Form Form 9 ARCHDIOCESE OF WASHINGTON- Catholic Schools NOTE: This is a release and indemnification agreement authorizing the administration of inhaled medication only. PART I: TO BE COMPLETED BY PARENT/ GUARDIAN Student’s Name: Sex: Birth Date: Male Female Print Name mm/dd/yyyy Student’s School: School Year/Grade: Allergies: Inhaler: Renewal New *If new, the first dose must be given at home. First dose was given: Date Time PART II: TO BE COMPLETED BY LICENSED HEALTHCARE PROVIDER WITH NO ABBREVIATIONS Diagnosis: List of Triggers: Signs or Symptoms: Medication and Route: Dosage to be given at School: Interval for Repeating Dosage: Time to be given: Common Side Effects: Effective Date: Start End If student is taking more than one medication at school, list the sequence in which medications are to be taken:
Inhaled Medication Authorization Form Form 9 ARCHDIOCESE OF WASHINGTON- Catholic Schools NOTE: This is a release and indemnification agreement authorizing the administration of inhaled medication only. PART I: TO BE COMPLETED BY PARENT/ GUARDIAN Student’s Name: Sex: Birth Date: Print Student’s Name Male Female mm/dd/yyyy School: School Year/Grade: Allergies: Inhaler: Renewal New *If new, the first dose must be given at home. First dose was given: Date Time PART II: TO BE COMPLETED BY LICENSED HEALTHCARE PROVIDER WITH NO ABBREVIATIONS Diagnosis: List of Triggers: Signs or Symptoms: Medication and Route: Dosage to be given at School: Interval for Repeating Dosage: Time to be given: Common Side Effects: Effective Date: Start End If student is taking more than one medication at school, list the sequence in which medications are to be taken:
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