2009-2011 - Santa Monica-Malibu Unified School District

ASTHMA MEDICATION
For Children Enrolled in City of Santa Monica CREST Programs
In January 2005, a new California law went into effect allowing students with asthma to carry and selfadminister
their prescribed asthma medication. This legislation amends the California Education Code
so that students with asthma would have immediate access to their potentially life-saving medications.
Previously, schools and school districts decided independently whether or not to allow students to carry
and self-administer asthma medication. Parents will now benefit from knowing that their children will
have their medication right when they need it.
To facilitate this new policy, the City of Santa Monica will allow participants in City programs who need
to take asthma medication prescribed by a physician to carry and self-administer inhaled asthma
medication with the written consent of the physician and parent/guardian.
1. PHYSICIAN CONSENT LETTER: Attach to this form a written statement from your physician which
includes the following information:
The name of the medication
How it is to be used
Dosage
Confirmation that the child is able to self-administer the medication.
2. PARENT CONSENT/REFUSAL STATEMENT
Child’s Name:
Medication:
Physician’s Name:
Physician’s Phone Number:
Please indicate whether you consent or refuse to allow your child to self administer medication.
If you consent, you must agree to all items listed below.
CONSENT:
______I consent to allowing my child to self-administer his/her asthma medication.
______I will allow camp staff to consult with my child’s physician named above if questions or
concerns arise.
______I absolve the City of Santa Monica and Rosie’s Girls staff from civil liability if my child
suffers an adverse reaction.
______I will provide the site with an extra inhaler should my child forget to bring his or her’s.
REFUSAL:
______I do not consent for my child to self administer her/his asthma medication.
______I would like for the site staff to administer medication per parent/guardian release and
instructions of our physician.
Parent/Guardian Signature
Date
35