BISHOP FENWICK HIGH SCHOOL
EPIPEN AND BENADRYL AUTHORIZATION FORM
School Year: ____________________
This form authorizes designated school personnel to administer Epinephrine (EpiPen) and/or Benadryl to a student in the event of a suspected allergic reaction or anaphylaxis, as ordered by the student's healthcare provider.
Student Information
Student Name: ______________________________________________
Date of Birth: _____________________ Grade: _____________
Known Allergies: ____________________________________________
Emergency Contact Name: ____________________________________
Emergency Contact Phone: ___________________________________
Healthcare Provider Authorization
Diagnosis/Allergy: __________________________________________
EpiPen Dose: EpiPen Jr. (0.15 mg) EpiPen (0.3 mg) □□
Benadryl Dose: _____________________________________________
Symptoms requiring EpiPen administration:
Symptoms requiring Benadryl administration:
Call 911 after EpiPen administration: Yes No □□
Additional Instructions: ____________________________________
Healthcare Provider Name: __________________________________
Phone: ______________________ Fax: _________________________
Provider Signature: _____________________ Date: _____________
Parent/Guardian Permission
I authorize Bishop Fenwick High School and its designated personnel to administer EpiPen and/or Benadryl to my child as prescribed above. I understand that emergency medical services may be activated when deemed necessary.
Parent/Guardian Name: __________________________________
Signature: ______________________________ Date: __________
Cell Phone: __________________ Secondary Phone: __________
School Nurse Authorization
School Nurse Review: _____________________________________
RN Signature: __________________________ Date: ___________