Anaphylaxis contract for self-medication.1-9-07

NOTE: This form is to be completed annually, in addition to district forms for the administration of prescription drug medication at school.
Pursuant to C.R.S. 22-1-119.5, a student with asthma, severe allergies, or other related, life-threatening conditions may possess and self-
administer medication to treat the condition if the student has an approved treatment plan. In accordance with state law and school board
policy, a student may be granted permission to self-carry and self-administer anaphylaxis medication. As such, the Cherry Creek School
District requires that parents and students complete this Agreement prior to granting a student permission to possess and self-administer
anaphylaxis medication. For purposes of this Agreement the terms “Epi-pen”/“Twinject”/“Benadryl” “Loratadine” will refer to the
prescribed anaphylactic medication.

I agree to be responsible for possessing and self-administering my Epi-pen/Twinject/Benadryl/Loratadine medication for myself at all times while attending school and/or attending school-sponsored events. I agree to possess and administer this medication in a responsible manner, in accordance with my physician’s orders. I agree to notify the school health office once I have administered this medication, or if I have difficulty in administering this medication. I agree to follow all school rules in terms of appropriate use of the medication and will not allow any other person to use my Epi-pen/Twinject/Benadryl/Loratadine medication. I agree that failure to abide by the terms of this Agreement and applicable school board policy will result in loss of the privilege to possess and self-administer this medication. ____________________________________________
This contract is in effect for the current school year unless revoked by the physician or the student fails to meet the above safety contingencies.

I/we agree to provide written medical authorization to the school for the medication prescribed that includes the signature of the health care practitioner, the name, purpose, prescribed dosage, frequency and length of time between dosages of the medication to be carried and self-administered by my/our student. I/we agree to provide confirmation from our health care practitioner that the student has been instructed and is capable of self-administration of the prescribed medication prior to the school granting permission for such use. I/we agree that, in return for the authorization for my/our student to possess and self-administer Epi-pen/ Twinject/Benadryl/Loratadine medication at school, I/we do hereby exempt and release Cherry Creek School District No. 5, it’s directors, officers, employees, volunteers and agents from any and all liability, claims, demands or actions arising out of any damage, loss or injury that my child or I/we sustain from my/our student’s possession and self-administration of the Epi-pen/Twinject/Benadryl medication. I/we agree to see that my/our student carries his/her medication as prescribed at school and/or at school sponsored events and activities, that the medical device contains the designated medication, and that the medication has not expired. I/we agree to review the status of my/our student’s medical condition on a regular basis as agreed upon in the student’s medical treatment plan. ____________________________________________
The school nurse will verify that the student has demonstrated correct technique for Epi-pen/ Twinject/Benadryl/Loratadine use, has evidenced an understanding of the health care practitioner’s order for time of administration and appropriate dosage, and has evidenced an understanding of the concept of pretreatment with Epi-pen/Twinject/Benadryl/Loratadine prior to engaging in any exercise. Appropriate school officials with a need to know have been notified of the student’s medical condition and the authorization to possess and self-administer the Epi-pen/Twinject/Benadryl/Loratadine medication. The school nurse will keep all appropriate records associated with the student’s possession and self-administration of the Epi-pen/Twinject/Benadryl/Loratadine medication. The school staff will call 911 if Epinephrine medication is used by a student. School staff understands to notify the health office if Benadryl is used. ______________________________________________



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