Authorization for Self-Administration of Epinephrine or Asthma Medication
HOPKINTON PUBLIC SCHOOLS
AUTHORIZATION FOR SELF-ADMINISTRATION OF EPINEPHRINE OR ASTHMA MEDICATION
Name of Student: ____________________________ Grade:________ H.R.: ____________
I wish my child to have the option of self-administering (circle one) an EpiPen / an inhaler to control asthma during his/her/their time in school and on field trips. I have discussed this option with my child’s physician and believe that my child has been sufficiently trained in self-administration.
Notes: There must be an AUTHORIZATION FORM FOR DISPENSING MEDICATION submitted with this form if none has been previously submitted.
School Committee policy requires that the prescriber, parent, and the school nurse support self-administration before this option is allowed.
Parent/Guardian Signature _______________________ Date ____________
Phone Number: ______________________
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