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Loomisgrammar.loomis-usd.k12.ca.us

3290 Humphrey Road, Loomis, CA 95650 (916) 652-1800 Building Excellence in Education since 1856 Phone: (916) 652-1824 Phone: (916) 652-2642 SCHOOL MEDICATION FORM

Student Name ______________________________________________________ Date of Birth

Parent’s Name
Phone (home)
Emergency Contact Name
Phone (home)________________Cell___________________
To Be Completed By Health Care Provider:
Diagnosis/Significant Findings:
Name of Medication or
Self- Carry?
Possible Side
Treatment
For Student with Severe Allergy – see LUSD Allergy Emergency Health Plan form
For Student with Asthma:
Does student need medicine before PE or sports?  No  Yes  PRN
Albuterol Inhaler- _____ puffs with spacer, 15-20 minutes before exercise; Other quick relief medication _________________________
If symptoms of coughing, wheezing, signs of difficulty breathing or _______________________:
1. Give quick relief medication Albuterol Inhaler _______ puffs (with spacer? Y___/N____)
Location of medication:
2. Have helper call guardian and school nurse
3. If symptoms do not improve, repeat in 5-10 minutes.
4. Call 911 if you see any of the following: Student having trouble walking or talking, stooped body posture, skin pulling in
around collarbone and ribs with breathing, continuous coughing, or lips or fingernails turning gray, blue, or purple
May give _______ puffs albuterol every 20 minutes (3 times maximum) until medical help arrives.

My signature below provides the authorization for the above written orders. I understand that all procedures will be implemented in accordance to CA
state laws and regulations. I understand that specialized physical health care services may be performed by unlicensed designated school personnel
under the training and supervision provided by the school nurse. This authorization is for the maximum of one year. If changes are indicated, I will
provide new written orders and authorization (may be faxed).

Health Care Provider Signature:


Address:

Phone: _______________
To Be Completed By Parent: I authorize the school nurse and/or other trained school personnel to assist my child in taking his/her medications
and treatments, and I authorize the nurse to consult with the Health Care Provider about my child’s medical needs as necessary while my child is at
school. I understand it is my responsibility to provide all medication, supplies and equipment and understand that if my child carries his own medication I
should provide extra to be kept in the office in case needed.
Parent Signature:
8/14/12 School Nurse Initial: Principal initial:

Source: http://loomisgrammar.loomis-usd.k12.ca.us/ourpages/auto/2011/2/28/53924969/LUSD%20school%20medication%20form%20_81412.pdf

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