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Ascension School - REQUIRED Emergency Medication Consent Form

Please complete the form below. Required fields marked with an asterisk *

According to Missouri State Statue Section 167.630, RSMo and 167.0635.1, RSMo schools are able to obtain and maintain an adequate supply of epinephrine pre-filled auto syringes and asthma-related rescue medications for emergency use by the employed school nurse licensed under chapter 335. The school nurse or another employee trained and supervised by the employed school nurse may administer these medications when they believe, based on training, that a student is having a life-threatening anaphylactic reaction or life-threatening asthma episode.

The St. Louis Archdiocese has adopted a new policy on Emergency Stock Medications. We have decided to stock Emergency Epinephrine and/or Albuterol for those students with no known history of anaphylaxis or asthma.

CONSENT

Parental approval to use standing physician ordered medications allows for efficient treatment of students emergency health issue.

I give my permission for the nurse or trained designee to administer appropriate standing physician ordered emergency medications for my child(ren).*

Answer required for "I give my permission for the nurse or trained designee to administer appropriate standing physician ordered emergency medications for my child(ren)."

Yes

Child 1 Name & DOB:*

Answer required for "Child 1 Name & DOB:"

Child 2 Name & DOB:

Answer required for "Child 2 Name & DOB:"

Child 3 Name & DOB:

Answer required for "Child 3 Name & DOB:"

Child 4 Name & DOB:

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Parent/ Guardian Name:*

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Signature*

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Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"