Chesapeake Form Hs001 – Fill Out and Use This PDF

Route of Administration and Instructions

In accordance with the Code of Virginia Section 22.1-274.2, by signing this form I attest to the student=s demonstrated ability to safely and effectively self-administer inhaled asthma medications and/or auto-inject epinephrine and of the student=s understanding that he is to report to the school nurse , or if the school nurse is not available, to the principal or his designee if self- administered medication as prescribed does not relieve the student=s asthmatic/allergic symptoms.

I further agree to prepare a written individual health care plan in consultation with the student=s parents, and appropriate school personnel.

In accordance with the Code of Virginia Section 22.1-274/2, I agree to the following:

I hereby give permission for the school to administer the medication as prescribed above.

I also give permission for the school to contact the above health care provider regarding the administration of this medication and the development of a health care plan.

I will not hold the school board or any of its employees liable for any negative outcomes resulting from the self- administration of said emergency medication by the student.

I understand that the school principal, after consultation with the parent(s), may impose reasonable limitations or restrictions upon a student=s possession and self-administration of said emergency medication relative to the age and maturity of the student or to other relevant considerations.

I understand that the school principal may revoke permission to possess and self-administer said emergency medication at any point during the school year if it is determined the student has abused the privilege of possession and self- administration or that student is not safely and effectively self-administering the medication.