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Kings Canyon SD |  E  5141.21  Students

Administering Medication   

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Respiratory Inhalers

I, (print) , Parent/Legal Guardian of

Student , Date of Birth ____/____/____

Give my permission for my child to be in possession of and to use his/her inhaler as needed. I further certify that I have provided the school office with a copy of the physician's signed request for the student to carry the inhaler with him/her and that I have instructed my child on the proper use of the inhaler. I accept responsibility for my child carrying his/her inhaler.

Give my permission for school office personnel to administer the inhaler to my child. I further certify that I have provided the school office with parent/guardian signed request and physician's signed instructions for the inhaler.

____________________________________ ____________________________

Parent/guardian Signature Date of Signature

RECEIPT OF THE ABOVE PERMISSION FORM AND REQUIRED INFORMATION

____________________________________ ____________________________

School Employee Signature Date of Signature

Exhibit KINGS CANYON JOINT UNIFIED SCHOOL DISTRICT

adopted: April 2, 2001 Reedley, California