7:270-E3 – Student Agreement to Carry and Self-administer an epinephrine auto-injector (EpiPen®) and/or medication prescribed for asthma at School or School Activities

Student Name: _________________________________ Date: ________________

Student’s School: ____________________________________

Medication: ___________________________________ Order Date: ___________

Physician/prescriber: _________________________________

As the above named student, my signature indicates my agreement while I am at school or school activities to the following:

  1. I have demonstrated the correct administration of the above listed medication to the School nurse.
  2. I agree to never share my medication with another person.
  3. I agree to take my medication only in accordance with the prescribed dosage instructions.
  4. I agree if there are any problems or lack of desired effects in or after use of the medication I will notify a school staff member for assistance. I will not proceed to the nurse with an escort. Parents should be notified of medication use through the school health office

Student’s signature _____________________________ Date: __________________

Student Agreement to Carry and Self-administer an epinephrine auto-injector (EpiPen®) and/or medication prescribed for asthma at School or School Activities

Student Name: _________________________________ Date: ________________

Student’s School: ____________________________________

Medication: ___________________________________ Order Date: ___________

Physician/prescriber: _________________________________

As the above named student, my signature indicates my agreement while I am at school or school activities to the following:

  1. I have demonstrated the correct administration of the above listed medication to the School Nurse.
  2. I agree to never share my medication with another person.
  3. I agree to take my medication in accordance with the prescribed dosage instructions.
  4. I agree if there are any problems or lack of desired effects in or after use of the medication, I will notify a school staff member for assistance. I will not proceed to the nurse without an escort. Parents should be notified of medication used through the school health office.

Student’s signature_____________________________ Date _____________________

Date Approved:    03/05/2011

Date Amended:  08/30/2016