Also for the overnight field trips: 5th grade Outdoor E
ducation or 8
grade Cleveland Tour PRESCHOOL, K-8TH
Elementary School Fax: 708-246-4625
Middle School Fax: 708-352-0092
NAME_______________________________________________________________________GRADE _________________ DOB___________________________                       
Dosage and Frequency, Physician Signature
1.__________________________________________________________3.______________________________________________ 2.__________________________________________________________ 4._____________________________________________ “OVER THE COUNTER” Medications approved for student (please checkmark each type for approval): Physician Signature required
Benadryl allergy tabs/(Spray for reaction) Other__________________________________________________________________________________________________________________
I do not want any medications given to my child during school hours. I understand by checking this space that I am willing to come to school to administer medications as needed.
Note - unless specified, dosage will be administered as per directions on medicine container
ASTHMA/INHALER SECTION Allergic to________________________________
Neb Treatment- Name/Medication______________________________________________Dosage_____________q______________Hours
ASTHMA ACTION PLAN Peak flow meter – My Personal Best = ______________________________
*Green Zone –
Breathing is easy, Can play, Work without symptoms* PEAK Flow Range 80%-100% of Personal Best
*Yellow Zone- Breathing easy, Coughing or Wheeze, Chest tight, SOB, PEAK Flow Range 50%-80% of Personal Best
*Red Zone Medicine NOT working, Nose open wide to breath, Breathing is hard and fast, Trouble walking and talking, Ribs show
If Symptoms do not get better Call 911 PEAK Flow Range below 50%
EPIPEN EMERGENCY PLAN SECTION Please note: each body system must be filled out
Allergic to:___________________________________________________________________________________________
Medication & Dosage:
Epipen 0.3mg Epipen Jr. 0.15mg Twinject 0.3mg Twinject 0.15mg

Benadryl 25mg- 50mg po
Mouth: Itching, tingling, or swelling of lips, tongue, mouth GIVE EPIEN TWINJECT BENADRYL
Skin: Hives, itchy rash, swelling of the face or extremities GIVE
Gut: Nausea, abdominal cramps, vomiting, diarrhea GIVE
Throat: Tightening of throat, hoarseness, hacking cough GIVE
Lung: Shortness of breath, repetitive coughing, wheezing GIVE
Heart: Thready pulse, low blood pressure, fainting, pale, blueness GIVE
Other: _______________________________________________ GIVE
If reaction is progressing (several of the above areas affected) GIVE
Parent signature below also grants permission for medical release of information to School Nurse to obtain Physician Signature if needed
I hereby confirm my primary responsibility to administer medication to my child. However, in the event that I am unable to do so, I hereby authorize Pleasantdale School District 107 and its employees and agents, in my behalf, to administer or to attempt to administer to my child(or to allow my child to self-administer, while under the supervision of the employees and agents of the District), lawfully prescribed medication in
the manner described above. I acknowledge that it may be necessary for the administration of medications to my child to be performed by an individual other than a registered nurse and specifically
consent to such practices.
I further acknowledge and agree that, when the lawfully prescribed medication is so administered or attempted to be administered, I waive any claims I might have against the District,
its employees and agents arising out of the administration of said medication. In addition, I agree to hold harmless and indemnify the District, its employees and agents, either jointly or severely , from and against
any and all claims, damages, causes of action or injuries incurred or resulting from the administration or attempts of said medication.

Source: http://www.d107.org/media/Administration/registration/NewStudent/11SchoolMedicationAuthorizationFormFinal.pdf

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