Bardstown City Schools Permission for Carry of
Rescue Inhaler (only permitted for students in grades 6-12)
Student____________________________________________________ Birthdate__________________
Homeroom Teacher_________________________________________
Grade_____________________
Allergies____________________________________________________________________________
Medication__________________________________________________Dosage_____________________
Frequency of self-administered dose(s)________________________________________________________
Reason for Medication ___________________________________________________________________
Special instructions / side effects___________________________________________________________
Participates on the following sports team(s)_______________________________________________________
driver
(please check all applicable boxes)
PHYSICIAN TO COMPLETE THIS PORTION (INITIAL EACH INDIVIDUAL LINE, THEN SIGN)
.

I confirm that the student has been instructed and is capable of self-administering the above prescribed
medication(s). This student is required to carry the prescribed medication on his/her possession at all
times.
Physician Signature__________________________________________________ Date____________
No stamps, please
Office phone_____________________________
STUDENT TO COMPLETE THIS PORTION (INITIAL EACH INDIVIDUAL LINE, THEN SIGN)

I agree to use my rescue inhaler as prescribed by my doctor above. I understand my asthma triggers,
symptoms, and treatment plan, including the difference between when to use any preventative medications
and my rescue inhaler.

I agree to keep my rescue inhaler with me in my possession at all times.

I agree never to share my rescue inhaler with others.

I realize that it is important for me to notify the School Nurse, as well as my parent/guardian, if I am
having more difficulty than usual with my asthma.
Student Signature___________________________________________Date_______________________
PARENT/GUARDIAN MUST COMPLETE BACK PAGE
PARENT/GUARDIAN TO COMPLETE THIS PORTION (INITIAL EACH INDIVIDUAL LINE, THEN SIGN)

My student has demonstrated the proper use of the rescue inhaler in my presence.

My student understands his/her asthma triggers, symptoms, and treatment plan, including the difference
between when to use preventative medications and rescue inhaler. He/she understands the importance of
letting his/her parents and school staff know when he/she is having more difficulty than usual with his/her
asthma.

I understand my child’s rescue inhaler must have a valid prescription label attached.

I give my permission for my student to keep his/her rescue inhaler with him/her and to self-administer
this medication in the school setting.

I understand it is recommended that I provide an extra back-up rescue inhaler to be kept in the School
health clinic.

I agree to be responsible for seeing that the inhaler my student carries with him/her (and/or is kept in the
School Health Clinic) is the correct medication and dosage, that his/her inhalers have medication in them,
and that his/her inhalers are not expired.

I agree to regularly review with my student the proper use of his/her rescue inhaler to include frequency,
procedure, and documentation usage while at school.

I agree to regularly review the status of my student's asthma with him/her and his/her physician and to
notify his/her physician when he/she is having more difficulty than usual with asthma.

I agree that the school district or school employee is not liable for damages if there is an act or omission
related to my student's use of their medication.

I give my permission for the information on this Health Care Plan to be shared with adults in the school
setting that will be working with my child on a need-to-know basis, including Transportation.

I understand that Bardstown City School staff have the authority to contact my child’s prescribing
physician and pharmacy as deemed necessary for the safety and well-being of my child.

I understand this Health Care Plan will remain in effect for the current school year only, unless revoked by
the parent, physician, or school nurse, or if the student fails to comply with this contract.

I understand it is my responsibility to notify the school nurse whenever there is a change in the student's
health status or care.

I understand this Health Care Plan and any nurse delegation related to this plan are for use during normal
operational school hours. After hours, school staff will be instructed to call 911 for any medical
emergencies or parents/guardians for concerns.
Parent signature_______________________________Date_________________Phone_______________
SCHOOL NURSE TO COMPLETE THIS PORTION (INITIAL EACH INDIVIDUAL LINE, THEN SIGN)

I have reviewed this contract. I agree to notify the school staff that have a "need to know" about this
student's condition and the need to self-carry a rescue inhaler.
School Nurse Signature_______________________________________Date_______________________