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SOMERSET HILLS SCHOOL DISTRICT Bernardsville, NJ 07924 AUTHORIZATION FOR
SELF-ADMINISTRATION OF ****(EPI-PENS AND
INHALERS ONLY)**** Date:___________________ Student's name:__________________________________ Grade: _________________ Date of birth:___________________________ Medication:______________________________________________________________ Dosage: ________________________________________________________________ Time:___________________________________________________________________ Reason for medication:_____________________________________________________ Any side effects or adverse
reactions?_________________________________________ I hereby certify that the student listed above has been instructed in and is fully capable of the self-administration of the above emergency medication. The student is capable of carrying this
medication during school and at school activities and to self-administer
it. Physician's name: (please print):_____________________________________________ Physician's signature:_____________________________________________________ Physician's phone
number:_________________________________________________ *****Parent/Guardian's signature:_____________________________________________ |