School Asthma Medication Consent Form
Complete this form to authorize school staff to administer your child’s asthma medication and to provide the medication details and emergency contact information needed by the school.
Student Information
Student full name
*
First Name
Middle Name
Last Name
Date of birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade / class
*
Homeroom teacher
School name
*
Allergy or asthma notes
Parent/Guardian and Emergency Contact Details
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Student
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Alternate Emergency Contact Name
*
First Name
Middle Name
Last Name
Alternate Emergency Contact Relationship
*
Alternate Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Please Select
Phone
Email
Text Message
Either Phone or Email
Asthma and Medication Information
Asthma diagnosis confirmation
*
Please Select
Diagnosed by provider
Suspected/under evaluation
No formal diagnosis but asthma-like symptoms
Other
Condition description
Medication name
*
Medication type/form
*
Please Select
Metered-dose inhaler
Dry powder inhaler
Nebulizer solution
Oral medication
Other
Dosage
*
How often medication should be given
*
Please Select
As needed
Before exercise
At scheduled times
Daily
Twice daily
Three times daily
Other
Special administration instructions, known triggers, or symptoms to watch for
Prescribing Provider Information
Provider Name
*
First Name
Middle Name
Last Name
Clinic / Practice Name
*
Office Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Prescription / Authorization Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
School Medication Supply and Instructions
Medication supplied in original labeled packaging?
*
Yes
No
Quantity provided to the school
*
Expiration date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Storage instructions
May the student self-carry or self-administer medication?
*
Yes
No
Side effects or precautions the school should know about
Consent and Signature
Consent and authorization
Parent/guardian signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Form
Submit Form
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