Consent for Assistance in Administering an EpiPen Form

Anaphylaxis Alert Information

Emergency Contact Information

Parent/Guardian informed authorization and release for the assistance in the administering of an EpiPen:

I have requested that an EpiPen be administered in the event of an anaphylaxis emergency. I/we understand that this service will be provided by a person without medical or nursing training. I understand that Recreation Services program/facility staff will only assist in the administration (Participant’s hand on EpiPen; staff hand over Participant’s hand) of an EpiPen. I agree to provide Recreation Services staff with a written and up-to-date medical statement whenever there is a change in the physician’s instructions with respect to medication. I also agree that the Participant will carry the Epipen on their person at all times. Should the Participant arrive at the program without their EpiPen, they will be removed from program activities until a Parent/Guardian can arrive on site with the EpiPen or pick up the child.

I am fully aware that the City of Oshawa and Recreation Services are in no way to provide or promise a risk-free or allergen-free environment for my child.

This form may contain personal information as defined under the Municipal Freedom of Information and Protection of Privacy Act. This information is collected under the legal authority of the Municipal Act, 2001, S.O. 2001 c.25, as amended. This information will be used and maintained by the City of Oshawa to provide camp staff with the information required to administer an Epi Pen. Questions regarding this collection may be directed to the City’s Information Access and Privacy Officer at 905-436-3311.