Authorization for Student Self-Carry and Administration of Medication (Inhaler) for at School & After School Activities
REQUIRES PHYSICIAN TO COMPLETE WITH PHYSICIAN'S SIGNATURE (PHYSICIAN SECTION).
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Applicable to 6-8th Grade Students Only
Per Concordia's policy, 6-8th students may self-carry with completion of this form and the physician's approval.  Administration/staff will reserve the right to request a student medication administration be supervised, even if student administers own medication at home.
CONCORDIA LUTHERAN ELEMENTARY SCHOOL
4245 Lake Avenue
Fort Wayne, IN  46815
Phone:  (260) 426-9922 x200
Fax (260)422-6980
Michelle Horn, RN
Email:  shorn@clscubs.org
Student's Name
Student's Date of Birth
Student's Grade
Medication Name:
Dosage:
Time to be Taken
Time
:
Physician's Name & Phone #
Physician
Physician, please check any statements listed below that you support
Physician's Office
Please print completed form to send with parent to return to school,  fax to school at 260-422-6980,  or email to Michelle Horn, RN at shorn@clscubs.org.
Physician's Signature
MM
/
DD
/
YYYY
I understand that this electronic signature below provides the same legal standing as a handwritten signature
Student's Signature
MM
/
DD
/
YYYY
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