Asthma/Anaphylaxis Medication Self-Administration Form

Asthma Self Administration Permission Form

The Missouri Safe Schools Act of 1996 (Pupils and Special Services Section 167.627, revised August 28, 2009) provides for students to carry and self-administer life-saving medications when the following criteria are met:

1) Written authorization by the parent/guardian
2) Medical history of students’ asthma or anaphylaxis on file at the school
3) Written asthma action plan/individual health care plan on file at school
4) Written authorization from the prescribing health care provider that child has asthma or is at risk of having anaphylaxis, has been trained in the use of the medication and is capable of self-administration of the medication.

THIS MEDICATION AUTHORIZATION IS ONLY VALID FOR THE CURRENT SCHOOL YEAR

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