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