Parental Authorization and Release Form for the Self-Administration of Epinephrine via EPI
I authorize my child, _________________________, to carry an epi-pen auto-injector and to self-administer his/her own epinephrine at school in the event of an emergency following my child’s:
• Demonstration of his/her knowledge and understanding of anaphylaxis and correct usage of the epi-pen to the school nurse;
• Agreement never to share the epi-pen with another student; and
• Agreement to obtain or send for assistance from the school nurse or another adult immediately in the event of an allergic reaction and/or use of the epi-pen.
______________________________________________________________________
Parent or Guardian Signature Date
The Following to Be Completed by the Student’s Physician:
I have prescribed an epi-pen auto-injector in the following dosage _____________________ to _______________________for his/her allergy/allergies to the following (list all applicable allergies):____________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
I have further instructed him/her with respect to:
• The events surrounding the need for epinephrine;
• The consequences of incorrectly administering epinephrine;
• The signs and symptoms of an allergic reaction; and
• The correct usage of an epi-pen.
________________________________________________ ________________.
Doctor's Signature Date