Williamson County Schools

AUTHORIZATION TO ASSIST STUDENTS WITH EMERGENCY ADMINISTRATION

OF EPI-PEN INJECTION

Dear Parent(s),

The administration of prescription emergency medication can only be done if you understand the information below, provide your physician’s authorization, and your written consent. Please read the information carefully. Thank you for your cooperation.

1. Prescription medication can only be administered at school when it is required to maintain the health of

the student.

2. Medication must be brought to school by parent/guardian, for the student for whom it was prescribed. It

must be in the original container, exactly matching the physician’s order, and labeled by the pharmacy to

include the following:

a. Name of student

b. Name of physician

c. Name of medicine

d. Instructions as to dosage, amounts, exact time, and route.

3. Two epi-pens should be available at all times in case of malfunction of one of the pens.

_____________________________ ________________ _______ _____________ ___________________

Student’s Name School Grade Date of Birth Medication Allergies

___________________________ __________________ To be administered at________________

Name of Medication Dosage and Route Time

__________________________________________________________________________________

PARENT/GUARDIAN PERMISSION:

I acknowledge that the above named student is competent to self-administer this medication with assistance or the medication may be administered by the school nurse or trained school personnel while in attendance at school. I give permission for my child to self-administer this medication with the supervision of a designated school employee. I agree to hold the Williamson County Board of Education harmless for the administration of such medication. I give permission for my health care provider and Williamson County Schools to send or receive a fax of this medical record.

________________________________ ________________ ___________________

Name of parent/guardian Home # Work #

______________________________________ ____________

Signature of parent or guardian Date

***********************************************************************************

PHYSICIAN’S AUTHORIZATION FOR ADMINISTRATION (To be completed by physician)

The above named student is under my medical supervision.

Reason for medication to be administered at school:__________________________________________

Possible reactions/side effects:___________________________________________________________

Special instructions for storage/handling:__________________________________________________

Name of Physician:___________________________________ Date prescription expires____________

______________________________________ ___________________ ______________

Signature of Physician Title Date

_____________________________________________ ________________ ________________

Address Phone # Fax #

Revised 04-03 Form #3