MCLEAN BIBLE CHURCH, TYSONS CAMPUS - KID’S QUEST

HEALTH INFORMATION AND EPIPENâ ADMINISTRATION POLICIES AND PROCEDURES

Overview:

Kid’s Quest is dedicated to bringing church and family together for a child's spiritual growth. To do this, we must provide a safe environment for the children who attend our programming. One way we do this is to be aware of any medical problems a child has, including allergies. We know that allergies are caused by various sources such as certain foods (peanuts, tree nuts, milk, wheat, etc.), animal allergies, insect stings or bites, medication, environmental agents, latex, etc. and that reactions range from mild to severe. We also understand that some children suffer from other health issues such as asthma or diabetes and could be affected by aspects of our programming.

To help us care for your child, we ask you to complete the attached Detailed Health Form. If your child has severe allergies and may require the administration of an EpiPenâ, we ask that you also complete and return the reverse side of the Detailed Health Form, as well as a half-sheet EpiPenâ Administration Permission Form which we require to accompany your child’s EpiPenâ in a zip lock bag. Allergy policies and forms can be obtained at check-in stations during weekend services, or on the Kid’s Quest web site at mbcbethesda.org/kqpolicies. If you have any questions or concerns, please contact Alisha Dodd at 703-639-2000 x3150 or .

Snack Policies:

  1. Kid’s Quest strives to be a “tree nut-free and peanut-free zone” anytime Kid’s Quest programming is happening. The staff will do our due diligence to screen snacks we provide against a list of tree nut and peanut allergens and will do our best to include any snacks brought by a parent/teacher.
  2. The following are foods that are generally served:
  3. Infants through Crawlers – no food is served, only parent-provided
  4. Walkers – Cheerios (contains: wheat, corn)
  5. Hikers through Little Adventurers – Cheerios (contains: wheat, corn)
  6. Preschool - Pretzels (contains: wheat, corn)
  7. Kindergarten through First Grade– Pretzels (contains: wheat, corn)
  8. Parents are welcome to bring snacks for their own child if he or she cannot have any of the above items, provided that the snack is in its original packaging with the ingredient list intact.
  9. A list of ingredients for snacks will be available in bins for Nursery through Preschool classes, and in Elementary classes will be displayed in large group areas on days when snacks are being served.
  10. Snack containers are washed between uses to prevent cross-contamination between different food products.
  11. Outside snacks are sometimes brought in for special occasions. Parents are responsible for watching for any “Special Snack” signs outside the classroom door or in large group areas. Whenever possible, original snack packaging for special snacks will be available so that parents may read the ingredient list.

Health/Allergy Forms Information:

  1. We encourage any parent or guardian whose child has allergy or health concerns to submit a Detailed Allergy Form. If the child may require the use of an EpiPenâ, please also complete the reverse side of the Detailed Allergy Form.
  2. Forms can be obtained at check-in stations or on the Kid’s Quest web site at www.mbctysons.org/kqenroll
  3. New Detailed Allergy Forms will be distributed at the start of each school year so we can update our records.
  4. A new Detailed Allergy Forms may be submitted during the year if there is a change in the child’s allergies and/or dosage or conditions under which EpiPensâ are to be given.
  5. A half-sheet EpiPenâ Administration Permission Form should be completed and included in a zip lock bag with provided EpiPensâ, consistent with EpiPen policies below. EpiPenâ Administration Permission Forms may be reused from week to week.

EpiPenâ Policies:

  1. Kid’s Quest staff and volunteers are not professional medical personnel. However, basic EpiPenâ administration training is offered for staff and key volunteer leaders.
  1. We do not provide EpiPensâ. They must be prescribed by a physician for a specific child and brought to Kid’s Quest by a parent each time the child is in attendance.
  1. If a child requires the possible use of an EpiPenâ, we must have the following:
  2. A Detailed Allergy Form completed on both sides and signed by the parent/legal guardian.
  3. EpiPensâ (preferably two) inside a zip lock bag including the completed half-sheet EpiPenâ Administration Permission Form. EpiPensâ must be properly and clearly labeled with:
  4. The child’s first and last name
  5. The dosage of Epinephrine
  6. The expiration date (We will not accept expired EpiPensâ)
  1. Kid’s Quest will not administer any medication except for an EpiPenâ in the event of an emergency.

Procedures:

  1. If your child has any health issues or allergies, pick up a green “Allergy/Health Issues” sticker at any Check-In Station or at your child’s classroom door (in nursery - preschool). Complete the requested information and place the sticker on the back of your child to alert the staff and volunteers. If needed, feel free to use more than one sticker.
  1. Tell the classroom door greeter about your child’s health issues or allergies each time you take him or her to class or an event. We strongly suggest that you attend the same service each week so staff and volunteers become familiar with your child’s specific needs and can provide the best possible care for your child.
  1. If your child may require the use of an EpiPenâ, place the EpiPensâ (preferably two) into a zip lock bag with the completed half-sheet EpiPenâ Administration Permission Form which may be reused from week to week.
  1. The zip lock bag is to be hand-delivered to the teacher or adult in charge of the classroom or event unless the child is approved to carry his or her own EpiPensâ.
  2. EpiPensâ should be put by the classroom staff or volunteer into the Emergency Bins located inside all small group classroom doors and large group areas where they can be picked up by parent at the end of the service. A classroom greeter can show you the location of the bin for your child’s specific classroom and/or age group.
  3. Should a child stay in the classroom for two services, a Kid’s Quest Coordinator will be responsible for moving a child’s EpiPenâ to his or her new location, if applicable.
  4. If your child has an anaphylactic reaction and has an EpiPenâ, the following will be done:
  5. The EpiPensâ in their respective zip lock bag will be retrieved from the Emergency Bin.
  6. A Kid’s Quest staff member or volunteer will check the half-sheet EpiPenâ Administration Permission Form in the zip lock bag to determine parent permission and EpiPenâ dosage information.
  7. An EpiPenâ will be administered by a Kid’s Quest staff member or volunteer.
  8. The Rescue Squad will be called by dialing 911.
  9. The parents or legal guardian will be called by LED number on their key tag or by cell phone number.
  10. The McLean Bible Church MERT (Medical Emergency Response Team) will be called, if available.
  1. Take your child’s EpiPensâ with you at the end of the class or event. The Kid’s Quest staff is not responsible for any medication left at MBC and does not store EpiPensâ overnight. If you accidentally leave EpiPensâ, you will be called to come pick them up from a locked cabinet located in Kid’s Quest Volunteer Central (located by the Café).


DETAILED HEALTH FORM

(Part 1 – Health and Allergy Concerns)

Child’s Name: Birth Date: Age:
Father’s Name: Cell Phone:
Mother’s Name: Cell Phone:
Legal Guardian’s Name: Cell Phone:
Doctor’s Name: Office Phone:

□ My child has diabetes

□ My child has asthma

□ My child has ______

My child is allergic to:

□ Food (peanuts, tree nuts, shellfish, etc.)

Please specify:______

Type of reaction:______

□ Animals, or Insect stings or bites (dogs, cats, bee stings, fire ants bites, spider bites, etc.)

Please specify:______

Type of reaction:______

□ Drug or Medication (Penicillin, etc.)

Please specify:______

Type of reaction:______

□ Environmental Agents (dust, pollen, mold, animal dander, poison ivy or oak)

Please specify:______

Type of reaction:______

□ Latex

Type of reaction:______

□ Other

Please specify:______

Type of reaction:______

□ My child no longer has allergic reaction symptoms to:______

______

If your child has a severe allergy that requires the administration of an EpiPenâ, please complete the EpiPenâ Administration Permission Form on the reverse side of this form.

I have read and understand that Kid’s Quest will not administer any medication except for an EpiPenâ by a trained staff member or key volunteer in the event of an emergency.

______

Parent or Legal Guardian Printed Name Parent or Legal Guardian Signature Date

DETAILED HEALTH FORM

(Part 2 - EpiPenâ Administration Permission)

To be completed by parent or legal guardian and kept on record by Kid’s Quest staff:

Child’s Name (as it appears on the EpiPenâ):______

I hereby authorize the McLean Bible Church (MBC) Kid’s Quest staff and volunteers to administer an EpiPenâ to my child if he or she has known exposure and/or a severe allergic reaction to a specified allergen. I agree to release, indemnify, and hold harmless MBC and any of its staff, volunteers, or agents from lawsuit, claim, expense, demand, or action against them for administering the EpiPenâ provided they administer the EpiPenâ prescribed specifically for my child. I am aware that the injection will probably be administered by a trained staff member or volunteer who is not a healthcare professional.

I have read the Allergy Information and EpiPenâ Administration Policies and Procedures and agree to provide two EpiPensâ as required.

I understand that the 911 Rescue Squad will always be called when an EpiPenâ is administered to my child.

The following EpiPenâ has been prescribed. Check as appropriate:

□ EpiPenâ (the premeasured dose is 0.3mg. of Epinephrine)

Give the initial dose.

Repeat the dose in 15 minutes if the Rescue Squad has not arrived.

□ EpiPenâ Jr. (the premeasured dose is 0.15mg. of Epinephrine)

Give the initial dose.

Repeat the dose in 15 minutes if the Rescue Squad has not arrived.

□ My child has received adequate training on how and when to use an EpiPenâ and can use it properly in case of an emergency. He or she will carry EpiPensâ at all times.

______

Parent or Legal Guardian Printed Name Parent or Legal Guardian Signature Date

To be completed by a Kid’s Quest staff member/coordinator:

The above has been reviewed with the parent or legal guardian.

Additional remarks:______

______

______

______

Kid’s Quest Staff Printed Name Kid’s Quest Staff Signature Date

EPIPENâ ADMINISTRATION PERMISSION FORM
To be completed by parent or legal guardian and placed in zip lock bag with EpiPensâ:
Child’s Name (as it appears on the EpiPenâ):______
Child’s Age/Grade: ______Parent/Guardian Emergency Cell/Phone: ______
My Child is Allergic To: ______
I hereby authorize the McLean Bible Church (MBC) Kid’s Quest staff and volunteers to administer an EpiPenâ to my child if he or she has known exposure and/or a severe allergic reaction to a specified allergen. I agree to release, indemnify, and hold harmless MBC and any of its staff, volunteers, or agents from lawsuit, claim, expense, demand, or action against them for administering the EpiPenâ provided they administer the EpiPenâ prescribed specifically for my child. I am aware that the injection will probably be administered by a trained staff member or volunteer who is not a healthcare professional. I have read the Allergy Information and EpiPenâ Administration Policies and Procedures and agree to provide EpiPensâ as required. I understand that the 911 Rescue Squad will always be called when an EpiPenâ is administered to my child.
The following EpiPenâ has been prescribed. Check as appropriate:
□ EpiPenâ (the premeasured dose is 0.3mg. of Epinephrine)
□ EpiPenâ Jr. (the premeasured dose is 0.15mg. of Epinephrine)
□ My child has received adequate training on how and when to use an EpiPenâ and can use it properly in case of an emergency. He or she will carry EpiPensâ at all times.
______
Parent/Legal Guardian Printed Name Parent/Legal Guardian Signature Date
EPIPENâ ADMINISTRATION PERMISSION FORM
To be completed by parent or legal guardian and placed in zip lock bag with EpiPensâ:
Child’s Name (as it appears on the EpiPenâ):______
Child’s Age/Grade: ______Parent/Guardian Emergency Cell/Phone: ______
My Child is Allergic To: ______
I hereby authorize the McLean Bible Church (MBC) Kid’s Quest staff and volunteers to administer an EpiPenâ to my child if he or she has known exposure and/or a severe allergic reaction to a specified allergen. I agree to release, indemnify, and hold harmless MBC and any of its staff, volunteers, or agents from lawsuit, claim, expense, demand, or action against them for administering the EpiPenâ provided they administer the EpiPenâ prescribed specifically for my child. I am aware that the injection will probably be administered by a trained staff member or volunteer who is not a healthcare professional. I have read the Allergy Information and EpiPenâ Administration Policies and Procedures and agree to provide EpiPensâ as required. I understand that the 911 Rescue Squad will always be called when an EpiPenâ is administered to my child.
The following EpiPenâ has been prescribed. Check as appropriate:
□ EpiPenâ (the premeasured dose is 0.3mg. of Epinephrine)
□ EpiPenâ Jr. (the premeasured dose is 0.15mg. of Epinephrine)
□ My child has received adequate training on how and when to use an EpiPenâ and can use it properly in case of an emergency. He or she will carry EpiPensâ at all times.
______
Parent/Legal Guardian Printed Name Parent/Legal Guardian Signature Date

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KQ-POL-AL-EPI Rev 02.00.005