Epinephrine Emergency Administration Consent Form (2026-2027)

4.35F4--EPINEPHRINE EMERGENCY ADMINISTRATION CONSENT FORM
Student's Name

First NameMiddle Name or Middle InitialLast Name
School Building
This form is good for school year 2026-2027. This consent form must be updated anytime the student's medication order changes and renewed each year and/or anytime a student changes schools.

My child has an IHP developed under Section 504 of the Rehabilitation Act of 1973 which provides for the administration of epinephrine in emergency situations. I hereby authorize the school nurse or other school employee certified to administer auto-injectable epinephrine in emergency situations when he/she believes my child is having a life-threatening anaphylactic reaction.

The medication must be in the original container and be properly labeled with the student's name, the ordering provider's name, the name of the medication, the dosage, frequency, and instructions for the administration of the medication (including times Additional information accompanying the medication shall state the purpose for the medication, its possible side effects, and any other pertinent instructions (such as special storage requirements) or warnings.
Date of physicians order

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Circumstances under which Epinephrine may be administered
Other instructions
I acknowledge that the District, its Board of Directors, and its employees shall be immune from civil liability for damages resulting from the administration of auto-injector epinephrine in accordance with this consent form, District policy, and Arkansas law.
Parent or legal guardian signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

4.35F4--EPINEPHRINE EMERGENCY ADMINISTRATION CONSENT FORM