Sulbutamol Inhaler Including use of School Emergency Inhaler

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SULBUTAMOL INHALER

If your child is prescribed emergency, life saving asthma inhalers please bring the medication in to school in the original container with the prescription label attached. You will must complete this form before we can administer any medication. Please note we cannot administer other medication or over the counter medications including cough lozenges and painkillers.
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Child's Name* This field is required.
First Name
Last Name
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Class child is in* This field is required.
Nursery
Reception
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3
4
5
6
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You have previously informed the school that your child needs a Salbutamol inhaler. Please read and answer the questions below then sign and return this form to the school as soon as possible, thank you.
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I can confirm that my child has been prescribed an inhaler * This field is required.
YESNO
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I can confirm that my child has been diagnosed with asthma * This field is required.
YESNO
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My child has a working, in-date inhaler, clearly labelled with their name, which they will leave at school every day. * This field is required.
YESNO
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Name of medication and strength* This field is required.e.g. Ventolin 100 micograms
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Expiry Date of Medication* This field is required.e.g. 01-10-2022
Date
Day
Month
Year
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Dose to be given and how often* This field is required.
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In the event of my child displaying symptoms of asthma, and if their inhaler is not available or is unusable, I consent for my child to receive salbutamol from an emergency inhaler held by the school for such emergencies.

The above information is, to the best of my knowledge, accurate at the time of writing and I give consent to school/setting staff administering medicine in accordance with the school/setting policy.

I will inform the school/setting immediately, in writing, if there is any change in dosage or frequency of the medication or if the medicine is stopped.

I have read and understood this form.
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Parent Name* This field is required.
First Name
Last Name
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Signature of Parent* This field is required.
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