(1) A written statement from the student's health care practitioner that provides the name of the drug, the dose, the times when the medication is to be taken or the monitoring equipment to be used, the specified time period for which the medication or monitoring equipment is authorized to be used and the diagnosis or reason the medicine or monitoring equipment is needed. The student's health care practitioner shall indicate the potential of any serious reaction to the medication that may occur, as well as any necessary emergency response. The student's health care practitioner shall state whether the student is competent to self-administer the medication or monitoring equipment and whether the student is able to practice proper safety precautions for the handling and disposal of the medication and monitoring equipment.

(2) A written request from the parent or guardian that the school entity comply with the instructions of the student's health care practitioner. The parent's request shall include a statement relieving the school entity or any school employe of any responsibility for the prescribed medication or monitoring equipment and acknowledging that the school entity bears no responsibility for ensuring that the medication is taken by the student and the monitoring equipment is used.

(3) A written acknowledgment by the school nurse that the student has demonstrated that the student is capable of self-administration of the medication and use of the monitoring equipment.

(4) A written acknowledgment by the student that the student has received instruction from the student's health care practitioner on proper safety precautions for the handling and disposal of the medications and monitoring equipment. The written acknowledgment shall also contain a provision stating that the student will not allow other students to have access to the medication and monitoring equipment and that the student understands appropriate safeguards.