Microsoft word - 2013epi pen doc

               Tamarack Nature Center Epinephrine and Benadryl  
Medication Order and Consent Form 
Medication Order for Treatment
5287 Otter Lake Road, White Bear Township, MN 55110  of Anaphylaxis using Epinephrine and/or Benadryl
BY UNLICENSED STAFF OR PERSONNEL IN THE ABSENCE       Phone: (651) 407‐5350    Fax (651) 407‐5354  If your child needs/uses Epinephrine and/or Benadryl, please have your physician complete this form and return it to Tamarack Nature Center two weeks prior to first camp start date. Completed forms will be kept on file for one year Child’s Name: ___________________________ Date of Birth _________________ Gender: ______ Address: _________________________________________________________________________ The above named child has a hypersensitivity to:_______________________________________ This child is at risk for an anaphylactic reaction. The child carries Epinephrine via Epi-pen which should be administered for treatment and/or Benadryl given as ordered: _____ Administer EpiPen® (epinephrine)(0.3 mg) ____ Administer EpiPen Jr® (epinephrine)(0.15 mg)  _____ Administer Benadryl ® (diphenhydramine): Dose ________Route: _______Frequency_______  TREATMENT PROTOCOL:
If an exposure occurs, or is suspected to have occurred, treatment should begin immediately and
parents notified.
_____ Benadryl ® (diphenhydramine) should be administered following exposure. _____ Epinephrine should be administered immediately following exposure, regardless of symptoms. _____ Child should be monitored and epinephrine should be administered if the student develops symptoms consistent with a generalized reaction as described below:  shortness of breath, wheezing, any difficulty breathing  nausea, vomiting, abdominal cramps, diarrhea  other symptoms, specific to this child ___________________________________________ If symptoms do not improve within ______________________________, call 911. ___________________________________ _________________ Licensed ___________________ (_____)______________                Tamarack Nature Center Epinephrine and Benadryl  
Medication Order and Consent Form 
Parent/Guardian Permission for Treatment
5287 Otter Lake Road, White Bear Township, MN 55110       Phone: (651) 407‐5350   Fax (651) 407‐5354  of Anaphylaxis using Epinephrine and/or Benadryl
BY UNLICENSED STAFF OR PERSONNEL IN THE ABSENCE If your child needs/uses Epinephrine (Epi-Pen), please complete this form and return it to Tamarack Nature Center at least two weeks prior to first camp start date. Completed forms will be kept on file for one year Child’s Name: __________________ Birthdate ___________ Camp(s) Registered:____________ Address: ______________________________________________________________________ Parent/Guardian Name: __________________________________________________________ Address: ______________________________________________________________________ Home Phone: ________________________ Other Phone: ______________________ If parent/guardian is unavailable in emergency, contact: Name: ________________________________________________ ______________________________________________ Relationship to Child: ____________________________________ My son/daughter has the following allergy(s) which may require treatment with epinephrine (Epi-pen) and/or Benadryl ® (diphenhydramine) according to my child’s physician:_______________________ By signing this form, I hereby give permission to allow the administration of epinephrine by auto- injection (Epi-pen) and/or Benadryl ® (diphenhydramine) administration in the absence of a licensed health provider by an unlicensed staff member or personnel of Tamarack Nature Center who has been trained in administration of Epi-pen and Benadryl ® (diphenhydramine) administration in the event of an emergency of my son/daughter. I also allow Tamarack Staff and Personnel to share with appropriate medical personnel, information relative to this medication administration plan and/or event.   ____________________________________________ ________________________ Parent/Guardian Day Camp Coordinator
TAMARACK NATURE CENTER
5287 Otter Lake Road, White Bear Township, MN 55110
Phone (651) 407-5350 
 Epi Pen Permission 6/17/10 , updated 6/10/13 

Source: https://parks.co.ramsey.mn.us/tamarack/Documents/2013EpiPenForm.pdf