Administration of Epinephrine to Pupils

Administration of Epinephrine to Pupils

A pre-filled auto-injector mechanism containing epinephrine is a medical device used for the emergency administration of epinephrine to a pupil for anaphylaxis, which is a severe, potentially life-threatening allergic reaction.  Anaphylaxis can occur within seconds or minutes of exposure to a specific allergen (i.e. peanut butter and bee sting).  Unless treated immediately, it could lead to unconsciousness or even death. 

I authorize my child to receive EMERGENCY treatment via the pre-filled auto-injector mechanism containing epinephrine by the school nurse or other trained school personnel.  I also acknowledge that the district, school, school nurse and other school employees shall incur no liability as a result of any injury arising from the administration of epinephrine via a pre-filled auto-injector mechanism to the pupil and the parent(s) or legal guardian(s) shall indemnify and hold harmless the district and its employees or agents against any claims arising out of the administration of epinephrine via a pre-filled auto-injector mechanism, which may include, but not limited to headache, blurred vision, buzzing sensation in ears, sweating, shortness of breath, etc.

Please remember that this form is to address EMERGENCY situations ONLY.  Please contact the main office if you have any questions.  Thank you.

This permission is effective for the 2019-2020 school year only and must be renewed annually.