School District No. 9 P. O. Box 1280 East Helena, M

East Helena Public Schools

School District No. 9

P.O. Box 1280 * East Helena, MT. 59635

Superintendent/Administration Office [phone]

Eastgate Elementary School [phone] * Radley Elementary School [phone]

East Valley Middle School [phone]

“Success For All”

Asthma Medication Permission Form

Student’s Name ________________________________________________

School ___________ Grade ________ Teacher_______________________
Diagnosis _____________________________________________________
Medication ____________________________________________________
Time __________________ Dosage _______________________________
Special instructions _____________________________________________

Possible side affects ____________________________________________

_________________________ _______________________

Physician’s Signature/Date Parent’s Signature/Date

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_____ This student is capable of administering his/her inhaler appropriately and may carry it with him/her.

_____ This student’s medication should be kept in the nurse’s office.
_____ The Montana Student Asthma Action Plan has been completed and signed by both parent and physician.
______If possible, please provide the school with a back-up inhaler to be kept in the medication lockup for emergencies.
Physician’s signature ____________________________________________
Parent’s signature ______________________________________________