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This form is ONLY for students or athletes Asthma Inhaler Self-Administration Permission Form
Athletic Allergy/Asthma Treatment Information Form
School Year: ____________________ School: _____Christian Heritage Academy_____ Student Name _______________________________________ Birth Date ____________________ Grade _______________________ Emergency Parent Phone(s) _______________________________________________________________________________________ Activity/Sport: If student is in Grades 6-12, circle appropriate sport(s) that students may participate: Fall
Winter
Early Spring
Late Spring
Grades 6-8 Sports
Grades 9-12 Sports
Dear Parents, If you indicated on the school emergency form that your child has a severe al ergy or asthma, please indicate your preference for treatment during school or interscholastic sport activity. My child does not require medication after school or during this extra-curricular activity for the treatment of his/her asthma My child requires the use of an inhaler for asthma during the extra-curricular activity. He/she wil carry and administer his/her own medication. Physician forms must be on file with the School Nurse.
My child requires the use of an inhaler for asthma during the extra-curricular activity. I give my permission for my child to pick up the inhaler stored in the Health Office prior to the activity. My child requires the use of an EpiPen and/or Benadryl for the treatment of severe al ergy during the extra-curricular activity. He/she wil carry and administer his/her own medication. Physician forms must be on file with the School Nurse. My child requires the use of an EpiPen and/or Benadryl for the treatment of severe al ergy during the extra-curricular activity. I give permission for my child to pick up the EpiPen and/or Benadryl stored in the Health Office to my child prior to Please note: Students who self-carry or transport medication must hand it to the coach/staff member prior to the start of the activity.
The coach/staff member will place it in the emergency bag for ease of access should an emergency occur. At the end of the activity, the
student must retrieve the medication from the coach.
Parent Permission (All Grades):
I hereby give permission to Christian Heritage Academy personnel to allow my child to carry and use an asthma inhaler. My child knows how
to use the inhaler, when to use the inhaler and when to seek adult assistance. I understand that by making this request, school personnel
wil not be supervising or be responsible for the administration of this medication. However, if the student is unable to self-administer and is
experiencing a reaction, staff wil administer the medication.
Physician Permission (All Grades):
I hereby give permission to Christian Heritage Academy personnel to allow my patient to carry and use an asthma inhaler. My staff and I
have taught this child how to use the inhaler, when to use their inhaler and when to seek adult assistance. I understand that by making this
request, school personnel wil not be supervising the administration of this medication. However, if the student is unable to self-administer
and is experiencing a reaction, staff wil administer the medication.
M
Doctor edication _______________________________________________________________________________________________________ Directions_________________________________________________________________________________________________________ Sign Physician Name __________________________Physician Signature _______________________________Date ______________________ Office Phone Number _________________________________________Fax #__________________________________________________ Parent/Guardian gives permission to fax this form to Christian Heritage Academy at 847-446-5267. Parent Signature _____________________________________________________________ Date ________________________________
Here Student Signature (Grades 6-12) ________________________________________________ Date ________________________________
too!

Source: http://christianheritage.org/wp-content/uploads/2012/07/Asthma-Inhaler-Self-Administration-Permission-Form-2012-13.pdf