Required fields are marked with asterisks (*)

Consent for Assistance in Administering an EpiPen® at Camp

Camper's Full Name:

Camp(s) Attending:

Allergy description - life-threatening allergy to the following:

Epinephrine auto-injector(s) is stored in:

Emergency Contact

Full Name:

Relationship to Camper:

Phone Number:

Alternate Phone Number:

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 ervice will be provided by a person without medical or nursing training. In understand the Kawartha Lakes Parks and Recreation Division 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 the Kawartha Lakes Parks and Recreation Division 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.

I am fully aware that the Kawartha Lakes Parks and Recreation Division are in no way to provide or promise a risk-free or allergen-free environment for my child.

I consent to the above informed authorization and release:

Yes

Parent/Guardian Full Name:

Parent/Guardian Signature:

Clear

Personal information contained on this form is collected in pursuant to the Municipal Act, 2001 and will be used for the purpose of responding to your request. Questions about the collection of this information should be directed to the City Clerk or Deputy-Clerk at clerks@kawarthalakes.ca.