SPBS Administration of Inhaler Medication Permission Form

SAINT PASCHAL BAYLON SCHOOL

PARENT PERMISSION/AGREEMENT FORM
PERMISSION FOR THE USE OF PRESCRIPTION INHALERS TO BE CARRIED BY STUDENTS AT SCHOOL
Instructions for the Parent/Guardian: You may complete this form, then preview and print the PDF to bring to your Health Care Provider to fill out and sign before submitting it to our office.
2025-2026 Regulations Regarding the Administration of Medication During School Hours

1. GENERAL POLICY

a) No student shall be given medications during school hours except upon the written request from a licensed physician who has the responsibility for the medical management of the student. All such requests must be signed by the parent or guardian.

b) Permission forms for students to receive medications (both prescription and non-prescription) while at school must be renewed each academic year.

2. RESPONSIBILITY OF THE PARENTS OR GUARDIANS

a) Parents or guardians will assume full responsibility for the supplying of all medications.

b) No medications may be brought to school by students.

c) Parents or guardians shall deliver or cause to be delivered by an adult or an authorized employee of a pharmaceutical supplier, any medication to be administered under the provisions of this policy.

3. RESPONSIBILITY OF THE PHYSICIAN

a) A request form for each prescribed medication must be completed by the student's physician, signed by the parent or guardian, and filed with the school administrator or their designated representative.

b) The container must be clearly labeled with the following information:
i) Pupil's full name
ii) Physician's name
iii) Physician's telephone number
iv) Name of medication
v) Dosage, schedule and dose form

4. RESPONSIBILITY OF SCHOOL PERSONNEL

a) Pupils taking medication will be assisted by authorized school personnel. This shall be done in accordance with the physician's

b) All medications administered by school personnel are maintained in a locked and secure place.
This section is TO BE COMPLETED BY PARENT/GUARDIAN for PRESCRIPTION INHALER MEDICATION to be given at school as directed.
TO THE PARENT OR GUARDIAN:

The inhaler may be carried by the student and used as prescribed for this academic year, after this form has been filed with your school office.
CHILD'S LAST NAME:
Name of Student
Date of Birth

MonthDayYear
Date
Grade:
Date of expiration of prescription

MonthDayYear
Date
PLEASE SIGN THE FOLLOWING STATEMENT:

I request that the school permit my child to carry and use an inhaler during school hours as prescribed by his/her physician for the 2025-2026 school year.
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
Print Name
Please preview and PRINT this form as a PDF below and give to your Health Care Provider to complete before turning into the school office.
Should be Empty:

SAINT PASCHAL BAYLON SCHOOL

PERMISSION FOR THE USE OF PRESCRIPTION INHALERS TO BE CARRIED BY STUDENTS AT SCHOOL

This section is TO BE COMPLETED BY PARENT/GUARDIAN for PRESCRIPTION INHALER MEDICATION to be given at school as directed.