You can always press Enter⏎ to continue
Consent Form
For the use of a prescribed salbutamol inhaler and an emergency salbutamol inhaler for a child showing symptoms of asthma or having an asthma attack
START
Accessibility
Enabled Form
1
Your child's name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Submit
Press
Enter
2
Your child's date of birth
*
This field is required.
.
Date
Day
Month
Year
Previous
Next
Submit
Submit
Press
Enter
3
Your child's class
*
This field is required.
Please Select
Eric Carle Nursery
Anning
Turing
Adenegan
Nightingale
Rosen
Attenborough
Bridges
The Compass
Please Select
Please Select
Eric Carle Nursery
Anning
Turing
Adenegan
Nightingale
Rosen
Attenborough
Bridges
The Compass
Previous
Next
Submit
Submit
Press
Enter
4
Medical condition
*
This field is required.
Please Select
Asthma
Please Select
Please Select
Asthma
Previous
Next
Submit
Submit
Press
Enter
5
Name or type of inhaler
*
This field is required.
Previous
Next
Submit
Submit
Press
Enter
6
Expiry date
*
This field is required.
As indicated on the container
.
Date
Day
Month
Year
Previous
Next
Submit
Submit
Press
Enter
7
Please explain dosage and method instructions.
*
This field is required.
These should fall in line with those provided by the dispensing pharmacist.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Submit
Press
Enter
8
Are there any special precautions or other instructions the school needs to be aware of when administering the inhaler provided?
*
This field is required.
No
Other
Previous
Next
Submit
Submit
Press
Enter
9
Are there any side effects of the inhaler provided that the school needs to be aware of?
*
This field is required.
No
Other
Previous
Next
Submit
Submit
Press
Enter
10
Can your child administer the inhaler?
*
This field is required.
YES
NO
Previous
Next
Submit
Submit
Press
Enter
11
What procedures should be undertaken in case of an emergency?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Submit
Press
Enter
12
My child has been diagnosed with asthma and has been prescribed an inhaler.
*
This field is required.
YES
NO
Previous
Next
Submit
Submit
Press
Enter
13
My child has a working, in-date inhaler, clearly labelled with their name, which they will bring to school with them every day.
*
This field is required.
YES
NO
Previous
Next
Submit
Submit
Press
Enter
14
I have provided the school with a working, in-date inhaler for my child, clearly labelled with their name, which will remain in school.
*
This field is required.
YES
NO
Previous
Next
Submit
Submit
Press
Enter
15
If my child displays symptoms of asthma, and if their inhaler is unavailable or is unusable, I consent for my child to receive salbutamol from an emergency inhaler held by the school for such emergencies.
*
This field is required.
YES
NO
Previous
Next
Submit
Submit
Press
Enter
16
Your name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Submit
Press
Enter
17
Your relationship to the child named in this Consent Form
*
This field is required.
Previous
Next
Submit
Submit
Press
Enter
18
Emergency contact telephone number
*
This field is required.
Previous
Next
Submit
Submit
Press
Enter
19
Your email address
*
This field is required.
You will receive a copy of this submission via email
Previous
Next
Submit
Submit
Press
Enter
20
Signature
*
This field is required.
Powered by
Jotform Sign
Clear
Previous
Next
Submit
Submit
Press
Enter
21
Date and time of submission of Consent Form
*
This field is required.
.
Date
Day
Month
Year
1
2
3
4
5
6
7
8
9
10
11
12
7
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
49
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM
AM
PM
Previous
Next
Submit
Submit
Press
Enter
Should be Empty:
Question Label
1
of
21
See All
Go Back
Submit
Submit