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KL LogoConsent for Assistance in Administering an EpiPen® at Camp


Signs and Symptoms (check all symptoms specific to your child):

Emergency Contact

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:

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