3505F2: Indemnification for Self-Administered Asthma/Emergency Medication

Gooding Joint School District No. 231


STUDENTS                                                                                                           3505F2




I hereby state that I am a:

         Physician licensed pursuant to chapter 18, title 54, Idaho Code.

         Physician’s assistant licensed pursuant to chapter 18, title 54, Idaho Code.

         Advanced practice nurse licensed under section 54-1409, Idaho Code.

         A licensed health care professional trained in the evaluation and management of concussions who is supervised by a directing physician licensed under chapter 18, title 54, Idaho Code. My directing physician is                                , and his/her license number is

                            , and address is                             .

I further state that I have met with                                                      (hereinafter referred to as “student athlete”) to evaluate the student athlete for a concussion. I have discussed with the student athlete the potential ramifications of continuing to play sports after having received a concussion or exhibiting concussion like symptoms. I am satisfied that the student athlete can return to play and/or participate in school athletic leagues or sports without significant likelihood of danger or injury, and I therefore authorize student athlete to return to play and/or participation in school athletic leagues or sports.


Signature                                            Date                                        License No.




Signature of Directing Physician       Date

(if signed by a Licensed Health Care Professional)

Policy History:

Adopted on: July 17, 2012 Revised on:


Transcript Request Form

Please initial below to acknowledge that you are the student named above and that you have reviewed the information above and agree that it is accurate. By initialing below you endorse this document as legally binding in accordance with the e-sign bill S.761 and release the below initials in lieu of a signature.
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