Schneider Elementary School 309 N. John St Farmer City, IL 61842 309-928-2611 FAX 309-928-2195

Ryan Peyton, Principal

Permission to Administer Inhaler or Nebulizer Students are allowed to use an Inhaler or Nebulizer if permission is given by the physician and the parent. This is to insure that students have immediate access to life-saving medication.

If your student has an Inhaler or Nebulizer that needs to be given or used during the school year, you must sign and return this completed form. This medication form will remain in effect for the current school year. Please note that it is the parent’s responsibility to ensure that the medication has not expired.

Student: _______________________________________________

Date: ____________________

Diagnosis requiring medication: __________________________________________________________ To be completed by the student’s physician, physician assistant, or advanced practice RN: Name of Medication

Dose

Frequency

Side Effects

Physician’s Name (Please Print): ___________________________________________________ Physician Signature: _________________________________

Date: ___________________