Summer Programs at Cary Academy
EpiPen and Benadryl Authorization Form
Camper Name: ______
Parent or Guardian Name: ______
I hereby authorize Summer Programs at Cary Academy personnel to administer an epinephrine (EpiPen) injection (and Benadryl if physician authorized directive is provided) to my child, if needed. I agree to release, indemnify, and hold harmless Cary Academy Summer Programs personnel, employees, contractors or agents of the school from lawsuits, claim expense, demand or action against them for administering this injection. I am aware that the injection may be administered by an individual who is not a trained health care professional.
Select one option, please initial selection:
__I authorize my child to carry and self-administer, as medically necessary, his/her prescribed EpiPen. I confirm that my child has the knowledge and the skills to safely carry, handle and self-administer the EpiPen in camp. I also understand that I am responsible for my child’s actions and agree to release, indemnify, and hold harmless Summer Programs at Cary Academy personnel, employees, contractors or agents of the school from lawsuits, claim expense, demand or action, etc. as it relates to my child carrying his/her own EpiPen.
__ I request that Summer Programs at Cary Academy personnel carry my child’s EpiPen and administer it if medically necessary. The EpiPen will follow your child throughout the camp day.
__ If my child also has Benadryl (physician authorized), I understand that it will be stored in the Summer Programs office unless there is an activity or field trip scheduled away from campus. In that case, the instructor will carry the Benadryl during that time.
IMPORTANT-PLEASE READ:
- EpiPens that are to be carried by personnel must be checked in to the Summer Programs office located in the Middle School Room 121on Monday morning between 8:30a.m. and 8:45a.m. (for morning and full day camps) or in the afternoon between 12:30p.m. and 12:45p.m. (for afternoon camps).
- If my child also requires Benadryl (physician authorized), I understand that it will be kept in the Summer Programs office unless there is an activity or field trip scheduled away from campus. In that case, the instructor will carry the Benadryl during that time.
- Benadryl will only be administered if it is included in an allergy action plan provided by your child’s physician. Please include a copy of your child’s allergy action plan if it includes guidelines for administering Benadryl.
I understand that emergency medical services (EMS) will always be called when epinephrine is given, whether or not the student manifests any symptoms of anaphylaxis.
Parent or Guardian Signature Date
Allergy
Reaction
Date of Last Reaction
Allergy
Reaction
Date of Last Reaction