Emergency Self Carry Medication Information

1. Parent and prescribing physician must complete and sign the form below. This form will need to be updated in the event of a change in the type of emergency medication or dosage. The prescribing physician and
parent will need to complete a new form at the beginning of each new school year.
2. The student must be instructed in the procedure of self-administration by the prescribing physician and the
school nurse. The student must be capable of responsibly carrying properly labeled emergency medication in
an original container on his or her person.
3. The parent must assume the responsibility for monitoring the child on a daily basis to insure that the child is
carrying and administering the emergency medication as ordered.