506.5E3 Parental Authorization and Release Form for the Self-Administration of Epinephrine Auto-injector

I authorize my child, _________________________, to carry an Epinephrine  auto-injector and to self-administer his/her own epinephrine at school in the event of an emergency. I agree that my child shall only administer said medication, provided my child can do all of the following:

• Demonstrate his/her knowledge and understanding of anaphylaxis and correct usage of the epi-pen to the school nurse;
• Agree never to share the epi-pen with another student; and
• Agree 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 Epinephrine auto-injector.

______________________________________________________________________________

Parent or Guardian Signature                                                                                          Date

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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

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