River Vale,
OF EPI-PEN BY A DESIGNATED INDIVIDUAL
September 2005
Dear
________________________:
Principal
I hereby authorize the River Vale Board of Education
to designate a nurse, or in her absence her trained designee, to administer the
epi-pen to my child _________________________________
(Name
of child, please print)
Attached please find the written orders from Dr.
___________________________, my child’s physician, stating that my child
requires the administration of epinephrin for anaphylaxis and that he/she does
not have the ability to self-medicate.
I understand that if the procedures specified in the
NJSA 18A:40-12.5 are followed that the district shall have no liability, as a
result of any injury arising from the administration of a pre-filled, single
dose, auto-injector mechanism containing epinephrine to the pupil and I shall
indemnify and hold harmless the district and its employees.
_____________________________ ______________________________ _____________
Parent/Guardian, Name (print) Parent/Guardian,
Signature Date
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