BELLOWS FALLS UNION HIGH SCHOOL
PO BOX 429
Bellows Falls, Vermont 05101(802)463-3944 FAX: (802)463-9322
CHRISTOPHER HODSDEN
PRINCIPAL Permission to carry Inhalers
PHYSICIAN SECTION
It is my professional opinion that it is a medical necessity that ______________________________
Carry his/her ___________________inhaler during school hours. He/She has been instructed in use and demonstrates an understanding of the purpose, appropriate method and frequency prescribed.
Physician Signature__________________________________________________date________
PARENT SECTION
We/I request that _________________________________________be permitted to carry his/her inhaler during school hours. We consider him/her knowledgeable and responsible in using it only as prescribed by his/her physician, independently. We/I absolve the school of any responsibility in safeguarding our child’s inhaler.
Parent/Guardian Signature___________________________________________date_________
STUDENT SECTION
I______________________________________ accept the responsibility of carrying my inhaler in school. I will only use it appropriately as my physician has prescribed. If it does not relieve my asthma symptoms completely I will immediately go to the school nurse. I will keep it secure on my person at all times. I will not allow other students to hold, carry, play with, spray or use it in any way. If it is missing I will report it to administration immediately.
Student Signature__________________________________________________date_________
School Nurse______________________________________________________date_________
Principal_________________________________________________________date________
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