I authorize my child, _________________________, to self-administer his/her own asthma inhaler or airway medication at school. I understand that the Columbus Community School District and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from my child's self-administration of such medication. The school district, and its employees, acting reasonably and in good faith, shall incur no liability for any improper use of medication, or for supervising, monitoring, or interfering with a student's self-administration of medication. I understand and acknowledge that under state law my student is not required to demonstrate "competency" in order to be permitted to self-administer his/her own asthma inhaler or airway medication at school.
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Parent or Guardian Signature Date
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The Following to Be Completed by the Student’s Physician:
I have prescribed the following medication (asthma inhaler/airway medication)
______________________for this student__________________________
Name of Medication Students Name
In this dosage:_______________________________________________________
Dosage and Instructions (Frequency of Use)
For the purpose of:___________________________________________________________
__________________________________ _____________________
Doctor's Signature Date