Medication Form For Life Threatening Allergic Reaction To Be Completed By Healthcare Provider (Page 2 of 2) in pdf

HILLSBOROUGH TOWNSHIP SCHOOL SYSTEM

HEALTH DEPARTMENT

PARENT AUTHORIZATION FOR STUDENTS WITH PHYSICIAN’S PERMISSION

TO SELF-ADMINISTER

I give permission for my child to self-administer medication as prescribed on page 1 of this form for the current school

year as I consider him/her to be responsible and capable of self-administration of medication.. I understand my child is

to keep the medication for self-administration with him/her at all times. For an antihistamine prescribed to be self-

administered along with epinephrine for anaphylaxis, a single pre-measured dose of antihistamine, in its original

labeled container is to be kept with the student, along with the epinephrine, at all times.

_________________________________

_______________________________

___________

Parent/Guardian (Print)

Parent/Guardian Signature

Date

PARENT AUTHORIZATION FOR DELEGATES FOR EMERGENCY

ADMINISTRATION OF EPINEPHRINE

In accordance with N.J.S.A. 18A:40-12.5 and pursuant to Public Law P.L. 2007, c.57, the Department of

Education in consultation with the Department of Health and Senior Services shall require trained

designees for students enrolled in a school who may require the emergency administration of epinephrine

for anaphylaxis when the school nurse is not available, even when the student is authorized to self-

administer epinephrine.

By signing below, I acknowledge that:

1. I hereby give consent to the administration of the epinephrine via a pre-filled auto-injector

mechanism by the designees, determined by the school nurse, to my child for anaphylaxis when the

nurse is not available.

2. I understand that the school nurse shall determine that the designees have been properly trained in the

administration of the epinephrine via a pre-filled auto-injector mechanism using standardized training

protocols established by the Department of Education in consultation with the Department of Health

and Senior Services.

3. In accordance with N.J.S.A. 18A:40-12.5 and Board of Education regulation and policy (5330), the

school district and its agents shall have no liability as a result of any injury arising from the

administration of epinephrine via pre-filled auto-injector mechanism to my child.

4. I agree to indemnify and hold harmless the school district and its agents, members, servants and

employees, against any claims, suit, or action, including attorneys’ fees, which may arise as a result

of the administration of epinephrine to my child.

5. I understand that, by NJ state law, antihistamines and corticosteroids shall not be given by a delegate.

In the absence of the school nurse, any antihistamine and corticosteroid order will be disregarded and

a trained delegate will give only the auto-injectable dose of epinephrine.

_________________________________

_______________________________

___________

Parent/Guardian (Print)

Parent/Guardian Signature

Date

Emergency Contact 1. _________________________ Phone number ______________________

Emergency Contact 2. _________________________ Phone number ______________________

Revised 8/14

Medication Form For Life Threatening Allergic Reaction To Be Completed By Healthcare Provider Page 2

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