MCPS FORMS > STUDENT FORMS > Emergency Care for the Management of a Student with a Diagnosis of Anaphylaxis

Emergency Care for the Management of a Student with a Diagnosis of Anaphylaxis
Release and Indemnification Agreement for Epinephrine Auto Injector

The Epinephrine Auto Injector WILL NOT BE ADMINISTERED IN SCHOOL OR DURING SCHOOL sponsored activities without a parent/guardian signed authorization and waiver and a physician's order/authorization.

In accordance with Maryland State Regulations, the Epinephrine Auto Injector may be administered by unlicensed staff (MCDHHS School Health Room Aide or MCPS employee) that are trained by the school nurse. Unlicensed staff are not allowed to wait for the appearance and observe for the development of symptoms before administering the Epinephrine Auto Injector.

• This form is for: Parent/Guardian, School Health Staff
• Form number: 525-14
• Last revised: July 2011

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