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JLCD-FRM2

Authorization for Self-Administration of Epinephrine or Asthma Medication

HOPKINTON PUBLIC SCHOOLS 

SELF-ADMINISTRATION 

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: ______________________

8.6.2019