Sulbutamol Inhaler Including use of School Emergency Inhaler

1

Child's Name* This field is required.

First Name

Last Name

3

You have previously informed the school that your child needs a Salbutamol inhaler. Please read the three paragraphs below carefully then sign and return this form to the school as soon as possible, thank you.

4

I can confirm that my child has been prescribed an inhaler * This field is required.

YESNO

5

I can confirm that my child has been diagnosed with asthma * This field is required.

YESNO

6

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

7

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.

I have read and understood this form.

8

Parent Name* This field is required.

First Name

Last Name

9

Signature of Parent* This field is required.

Clear