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Epi Pen/Benadryl Medical Forms

Epi Pen/Benadryl Medical Forms

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Tamarack Nature Center <strong>Epi</strong>nephrine and <strong>Benadryl</strong>Medication Order and Consent Form5287 Otter Lake Road, White Bear Township, MN 55110Phone: (651) 407‐5350 • Fax (651) 407‐5354Parent/Guardian Permission for Treatmentof Anaphylaxis using <strong>Epi</strong>nephrine and/or <strong>Benadryl</strong>BY UNLICENSED STAFF OR PERSONNEL IN THE ABSENCEOF A LICENSED HEALTHCARE PROVIDERIf your child needs/uses <strong>Epi</strong>nephrine (<strong>Epi</strong>-<strong>Pen</strong>), please complete this form and return it to Tamarack Nature Center at leasttwo weeks prior to first camp start date. Completed forms will be kept on file for one yearChild’s Name: __________________ Birthdate ___________ Camp(s) Registered:____________Address: ______________________________________________________________________Street City State ZipParent/Guardian Name: __________________________________________________________Address: ______________________________________________________________________Home Phone: ________________________Other Phone: ______________________If parent/guardian is unavailable in emergency, contact:Name: ________________________________________________Phone(s) ______________________________________________Relationship to Child: ____________________________________My son/daughter has the following allergy(s) which may require treatment with epinephrine (<strong>Epi</strong>-pen)and/or <strong>Benadryl</strong> ® (diphenhydramine) according to my child’s physician:_______________________By signing this form, I hereby give permission to allow the administration of epinephrine by autoinjection(<strong>Epi</strong>-pen) and/or <strong>Benadryl</strong> ® (diphenhydramine) administration in the absence of a licensedhealth provider by an unlicensed staff member or personnel of Tamarack Nature Center who has beentrained in administration of <strong>Epi</strong>-pen and <strong>Benadryl</strong> ® (diphenhydramine) administration in the event ofan emergency of my son/daughter. I also allow Tamarack Staff and Personnel to share withappropriate medical personnel, information relative to this medication administration plan and/or event.____________________________________________ ________________________Parent/Guardian SignatureDatePlease return completed form to:Day Camp CoordinatorTAMARACK NATURE CENTER5287 Otter Lake Road, White Bear Township, MN 55110Phone (651) 407-5350<strong>Epi</strong> <strong>Pen</strong> Permission 6/17/10 , updated 6/10/132

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