Medical Alert Form School District No. 43, Coquitlam School Board Page 5
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5Authorization ‐ I agree to (select those that apply):
Supply the school with medications and up‐to‐date Epi‐pen(s).
Provide The Child with a medic alert bracelet and fanny‐pack for Epi‐pen.
Ensure The Child knows his/her responsibilities for his/her own safety.
Ensure The Child will have an Epi‐pen on their person. (It is strongly recommended that children have Epi‐pens
on their person at all times.)
I understand that my failure to do the above may result in an inability to implement timely emergency
procedures for this potential life threatening condition.
I authorize the staff of School District No. 43 and its agents, including volunteers, to execute the school’s
commitments as outlined within this plan.
I am aware that the Public Health Nurse for the school will be informed of my child’s condition and treatment
and that the nurse may contact me as necessary.
I give consent for the identification of The Child as a person with _____________________ (nature of
condition/risk).
I understand that this may include the display of pertinent information, including a picture of The Child in
strategic locations within the school. It is understood that the reason for this display is to enable the staff of
School District No. 43 and its agents to be able to respond to potential emergencies in a timely fashion. It is
clearly understood that student confidentiality will be maintained wherever possible.
I authorize the staff of School District No. 43 and its agents to administer the designated treatment and to
obtain suitable medical assistance. I agree to assume all costs associated with the medical treatment and
absolve the staff of School District No. 43 and the Coquitlam School Board of the responsibility for any adverse
reactions resulting from the administration of the designated medication.
If changes occur, I will contact the school and provide revised instructions. I am aware I am required to update
this information as needed.
This agreement is valid from the date signed until revoked.
Parent/Guardian Last Name
Parent/Guardian First Name
Date
Page 5 of 5
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