Consent to administer emergency epipen

 

For Children Prescribed an Epipen

We are required to renew the annual consent for the use of emergency epipens kept in school. These are used only in emergencies, if a child’s personal device is unavailable or fails.

To provide or decline consent, please complete the form below.

Please complete the form even if you do not wish to give consent, as there is an option to indicate this.

Thank you for your continued support in helping us keep your child safe and healthy.

 

Please complete all fields marked (*)

Your first name *

Your last name *

Your email *

Child's Full Name *

Please be advised the Walk to School Policy can be found on the policies page of this website.

Your relationship to the child *

Child's Year Group *

Nursery Reception Year 1 Year 2 Year 3 Year 4 Year 5 Year 6

Address *

Post Code *

I can confirm that my child has been diagnosed with an allergy and has been prescribed an Epipen. *

Yes

My child has a working, in-date Epipen, clearly labelled with their name, which is kept in school. *

Yes

In the event of my child displaying symptoms of anaphylaxis and if their Epipen is not available or is unusable, I consent for my child to be given the emergency Epipen held by the school for such emergencies. *

Yes, I give consent

No, I do not consent

Please provide a signature. *