Yes ___ No___ The student has been instructed in self-administration of the Epi-Pen.
Yes ___ NO___ I authorize my child to carry and administer own medication as prescribed by Physician.
I authorize the release and exchange of medical and educational information between my
child’s physician and school staff that is necessary in carrying out this service to my child.
Parent Signature __________________________
Date___________________
Phone numbers ___________________
Emergency contact_________________________
Phone numbers___________________
Physician PRINT ___________________________
Phone numbers __________________
Physician Signature_______________________________
Revised Mar 2014
Date__________________