Holbrook Public School

This form is not a substitute for the ASCIA Action Plan for Anaphylaxis or the Asthma Action Plan signed by the student’s doctor.

For some medications and some students it can be appropriate for them to carry their own medication to school and at school, for example, EpiPen® or Anapen® for anaphylaxis and asthma reliever medication for asthma.

For asthma and anaphylaxis it is important for students to have immediate access to their medication. Please consider whether your child should carry their own EpiPen®, Anapen® or asthma reliever medication to school and while they are at school.

On receiving this completed request form, the school will confirm the arrangements for how and where your child will carry their own medication.

You will still need to provide the school with at least one other EpiPen®, Anapen® and/or asthma reliever medication for storage in a central location/s within the school and for access by staff in case of an emergency.

If you would like the school to consider your request for your child to carry their medication, please complete the following information and return to:

Tracey Mullavey, SAM

Louise Purss-Semple, Principal

Student details

First name *

Last name *

Date of birth *

Class

My child has been diagnosed with (please select): *

I am requesting my child carry the following medication with them to school and at school (please select): *

Describe where and how your child will carry this medication, for example, my child will carry it on their person in a medical pouch or bum bag. *

Note:

■ Your child’s medication should be clearly labelled with their name.

■ Where the EpiPen® or Anapen® is carried by your child they will need to carry with it a copy of their ASCIA Action Plan for Anaphylaxis: www.allergy.org.au/health-professionals/anaphylaxis-resources/ascia-action-plan-for-anaphylaxis

■ For asthma reliever medication your child should carry with it a copy of their Asthma Action Plan: www.health.gov.au/internet/main/publishing.nsf/Content/asthma-plan

Name of the asthma reliever medication

Parent/carer details

Parent/Carer's name *

Relationship to student *

Street number/street name *

Suburb *

Postcode *

Home phone

Work phone

Mobile phone

Email *

Signature *

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Date *

Privacy notice:

The information requested on the form is essential for assisting the school to plan for the support of your child’s health needs.

It will be used by the NSW Department of Education and Communities for the development of arrangements with you to support your child’s health needs. Provision of this information is voluntary. If you do not provide all or any of this information, the school’s capacity to support your child’s health needs could be impaired.

This information will be stored securely. You may correct any personal information provided at any time by contacting the Principal.

Request for student to carry their Asthma or Adrenaline Autoinjector medication

Holbrook Public School