EPINEPHRINE PERMISSION & PHYSICIAN ORDER FORM
An Epinephrine permission and physician order form only needs to be completed if your child requires an Epi Pen or benadryl liquid for any life-threatening allergies. It provides permission for the school nurse or a trained delegate to administer an Epi Pen to your child should the need arise. Benadryl liquid may only be administered by the school nurse.
Please make sure to have the doctor complete ALL portions, sign, and stamp the form where indicated. Also please make sure to sign the bottom of the form as well. BOTH signatures are required in order for the school nurse to administer these medications to your child.
*If your child requires an Epi Pen or Benadryl in school, the food allergy plan form must also be completed by the doctor and parent. Please refer to the Food Allergy Plan Form page.
*A signed medication policy form is also required. Please refer to the Medication Policy Form page.
All medications must be brought to school by an adult in the original store or prescription container. Please do not send your child to school with medications for safety reasons and as per our medication policy. Please check all expiration dates and make sure the medication is not expired. Medications must be picked up by an adult at the end of the school year. They will not be sent home with your child. Any medications not picked up by the end of the school year will be discarded.
Download link is at the bottom of the page.