EpiPen - Homepage - Department of Education
EpiPen / EpiPen JrStudent InformationStudent’s NameMale Female Date of BirthSchoolClassName of Parent/GuardianPlace student’s photo herePhone (Home) Phone (Work)Phone (Mobile)Name of Alternative ContactRelationship to StudentPhone (Home)Phone (Work) Phone (Mobile) Name of Doctor / SurgeryTelephone (Surgery)List your child’s allergiesSite of Medical Alert BraceletLeft arm Right arm Neck Other What are the early warning signs for your child if experiencing an allergic reaction?When is this allergic reaction like to occur?How do you manage your child’s allergies (EpiPen, tablets, diet?)Does your child give own EpiPen injection? Yes No Medication NameDosageFrequencySide effectsAdditional information / instructionsPermission for school staff to administer EpiPen in an emergency Yes No Signature of Parent / GuardianDateSignature of PrincipalDateSignature of School NurseDateSignature of First Aid OfficerDate ................
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