Medication Authorization Forms

Asthma - Inhaler Authorization and Action Plan

If your child has asthma and requires an inhaler, please print out the asthma authorization form and take it to your child's physician.  Please ask the physician to fill out the action plan to give your child's nurse additional instructions in the event your child needs assistance. 

If you would like your child to carry their inhaler with them, his/her physician must sign the authorization form granting this permission.  We encourage an additional inhaler be provided to stay in the clinic.


Medication Authorization Form

Only medications that are required to enable a student to stay in school should be given at school. Medication to be given 3 times a day should be given before school, after school, and at bedtime unless a particular time is specifically noted by physician.

All medication should be in the original container and labeled with your child's name.  Please limit over-the-counter medication to be stored in the clinic to small quantities. 

Please print medication authorization form (for more than one medication print out separate forms), fill it out, and bring it with the medication to the clinic. 

Severe Allergy - Medication Authorization and Action Plan

If your child suffers from severe allergies that requires medication in the event of a reaction, please print out the authorization form to be filled out completely by you and your child's physician.
If you and your child's physician want the child to carry their EpiPen, then specific notation should be made by the physician to authorize this.