Use of Emergency Salbutamol Inhaler

Parent / Guardian consent form; To authorise use of the emergency salbutamol inhaler and GP contact.

Pupil Name* Class* GP Name* GP Address*

I confirm that my child has been diagnosed with asthma and /or has been prescribed a salbutamol inhaler in the last 12 months for an episode or wheezeYes

I confirm that my child has a working, in-date, salbutamol inhaler, clearly labelled with their name , which they will bring with them to school everyday or there is a working, in-date, salbutamol inhaler stored for use in the school.Yes

I confirm that my child has a spacer which they will carry with them in school everyday or which is stored for use in school.Yes

I confirm that my child has an up-to-date asthma management plan available at school.Yes

I consent for my child to receive salbutamol from an emergency inhaler held by the school in the event that my child shows symptoms of asthma or is having an asthma attack, and their inhaler is not available or is unusable.Yes

Signed* Date* Parent Name* Parent Address* Contact Telephone Number* Email Address*