Someries Infant School and Early Childhood Education Centre's Consent Form: Prescribed adrenaline auto-injector (epi-pen) and emergency adrenaline auto-injector (epi-pen)

1
Your child's name* This field is required.
First Name
Last Name
2
Your child's date of birth* This field is required.
Date
Day
Month
Year
3
Your child's class* This field is required.
Please Select
Please Select
Windsor
Lancaster
Warwick
Gosford
Tintagel
Edinburgh
Durham
Cardiff
York
The Compass
The Link
The Lighthouse
4
Medical condition* This field is required.
Please Select
Please Select
Anaphylaxis
5
Name or type of adrenaline auto-injector* This field is required.
6
Expiry date* This field is required.As indicated on the container
Date
Day
Month
Year
7
Please explain dosage and method instructions.* This field is required.These should fall in line with those provided by the dispensing pharmacist.
Huge
Large
Normal
Small
Ok
Ok
8
Are there any special precautions or other instructions the school needs to be aware of when administering the adrenaline auto-injector (epi-pen) provided?* This field is required.
No
Other
9
Are there any side effects of the adrenaline auto-injector (epi-pen) provided that the school needs to be aware of?* This field is required.
No
Other
10
Can your child administer the adrenaline auto-injector (epi-pen)?* This field is required.
YESNO
11
What procedures should be undertaken in case of an emergency?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
I confirm that my child has been diagnosed with an allergy which could cause anaphylaxis and has been prescribed an adrenaline auto-injector (epi-pen).* This field is required.
YESNO
13
My child has a working, in-date adrenaline auto-injector (epi-pen), clearly labelled with their name, which they will bring to school with them every day.* This field is required.
YESNO
14
I have provided the school with a working, in-date adrenaline auto-injector (epi-pen) for my child, clearly labelled with their name, which will remain in school.* This field is required.
YESNO
15
If my child displays symptoms of anaphylaxis, and if their adrenaline auto-injector (epi-pen) is unavailable or is unusable, I consent for my child to receive adrenaline from an emergency adrenaline auto-injector (epi-pen) held by the school for such emergencies.* This field is required.
YESNO
16
Your name* This field is required.
First Name
Last Name
17
Your relationship to the child named in this Consent Form* This field is required.
18
Emergency contact telephone number* This field is required.
19
Your email address* This field is required.You will receive a copy of this submission via email
20
Signature* This field is required.
Clear
21
Date and time of submission of Consent Form* This field is required.
Date
Day
Month
Year
10
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Hour
39
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Minutes
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Should be Empty: