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JLCD-FRM3

Self-Administration Form for Students on Overnight and Out of State Trips

Self Administration Form for Students on Overnight & Out of State Trips

Dear Parent/Guardian: 

District policy allows students to self-administer medications with school nurse and parent/guardian approval. In order for your child to carry and administer his/her/their own inhaler and/or epinephrine auto injector and/or insulin and/or other medication as prescribed by a licensed physician, you must complete part A of this form. Part B will be completed in the health office with your child. You may be present during the completion of part B (back) of this form if you so desire. Your child must be able to answer the questions in Part B or he/she/they will not be permitted to carry or administer his/her/their own medication. This is for the safety of your child and others. This form must be completed IN ADDITION to the parent and prescriber’s normal authorization form for administration of medication in school. 

A. To be completed by the parent/guardian: 

I request that my child ________________________ be permitted to carry on his/her/their personal: 

● Inhaler _________ 

● Epinephrine auto injector _______ 

● Insulin _______

● Other prescription/OTC medication (name(s)) _________________________________ ______________________________________________________________________ ______________________________________________________________________ 

My child has been instructed in and understands the purpose, appropriate method, frequency and use of his/her/their medication. My child understands that he/she/they is/are responsible and accountable for carrying and using his/her/their medication. My child understands that if he/she/they self administers this medication while on an Overnight or Out of State Field Trip that he/she/they will inform the school nurse or closest adult immediately after administration. It is understood that if there is irresponsible behavior or safety risk, the privilege of carrying his/her/their medication will be rescinded. I will support my child in following the agreement in Part B. 

_________________________________     __________________
 (Parent/Guardian Signature)       (Date) 

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JLCD-FRM3 

B.To be completed by the school nurse with student: 

Yes No 

____ _____ Student is consistently able to: 

                 ● Name the medication; Identify the correct medication; 

                 ● Explain the purpose of the medication; 

                 ● Knows the correct dosage; 

                  ● Explains when and how often the medication is to be taken; 

                  ● Describes what will happen if the medication is not taken; 

                  ● Knows where the medication will be safely stored 

____ _____ Student demonstrated the correct use/administration. 

____ _____ Student realizes his/her/their responsibility in carrying his/her/their own medication ____ _____ Student knows not to share the medication(s) with others. 

____ _____ The student agrees to notify the school nurse or closest adult immediately after self-administering his/her/their medication on school sponsored trips. 

____ _____ The student agrees to contact the nurse immediately upon taking the prescribed medication or with any questions, concerns or adverse side effects. 

The student understands that the privilege of carrying and administering his/her/their own medication(s) will be rescinded if he/she/they does/do not follow the above agreement. 

________________________      _________                      ____________________________                ____________
(Student Signature)           Date                          (School Nurse Signature)                     Date 

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