Huntley school district 158 - health services department

Consolidated School District 158 - Health Services Department
Epinephrine and BenadrylAdministration Authorization Form
Student’s Name:________________________Grade:_________ Student’s School: ____________________________
Address:__________________________________________ City: ____________ Zip Code:____________________
Name of Parent or Guardian:________________________________________________________________________
Home Phone: __________________________ Emergency Phone/Work:_____________________________________
The following is to be completed by the student’s physician:

**Notice to Physicians: 911 will be called when Epinephrine has been administered**

Name/Type of Epinephrine:_________________________________________________________________________
Dosage: ______________ Diagnosis Requiring Medication: ______________________________________________
When to administer Epinephrine and/or Benadryl:_______________________________________________________
_______________________________________________________________________________________________
Is medication to be carried on child?______________ If so, the Physician must complete the following:
I certify that ______________________________________ has been instructed in the use and self-administration
Name

of the Epi-Pen and Benadryl and that he/she understands the need for Epinephrine and Benadryl and the
necessity to report to school personnel any unusual side effects.
Physician’s Signature ______________________________________________ Date: ________________
Physician’s Name (Please print): ____________________________________________________________
Physician’s Address: __________________________________ City: _____________ Zip Code: ________
Office Phone Number: ___________________________ Emergency Phone Number: __________________
I confirm that I am primarily responsible for administering medication to my child. However, in the event that I am unable to
do so or in the event of a medical emergency, I hereby authorize Huntley School District 158 and it’s employees and agents, in
my behalf and stead, to administer or to attempt to administer to my child (or allow my child to self-administer, while under the
supervision of the employees and agents of the School District) lawfully prescribed Epinephrine and Benadryl in the manner
described above. I acknowledge it may be necessary for the administration of Epinephrine to my child to be performed by an
individual other than a school nurse, and specifically consent to such practices. I further acknowledge and agree that, when the
lawfully prescribed Epinephrine is so administered, or attempted to be administered, I waive any claims I might have against
the School District, its employees and agents arising out of the administration of said medication. In addition, I agree to hold
harmless and indemnify the School District, it’s employees and agents, either jointly or severally, from and against any and all
claims, damages, causes of action or injuries incurred or resulting from the administration or attempts at administration of
said medication. I agree to my child being able to carry their medication on them if needed.

Parent(s)/Guardian(s) Signature: __________________________________ Date: _________________

*Parents/Guardians, Please note that we will need this form completed each new school year by you and your physician.

Source: http://www.district158.org/health/Forms/Epinephrine%20self%20administration%20form.pdf