Clementon School District

EPI-PEN USE:

If your child has been prescribed an Epi-Pen for emergency use:

• Your child’s physician must complete and sign the Anaphylaxis Emergency Care Plan.
• The Parent/Guardian must sign the bottom of the Anaphylaxis Emergency Care Plan (remember to indicate on the bottom of the form if you wish for your child to sit at a peanut/nut free table at lunch).
• Epi-Pens must be in the prescription labeled box and hand delivered to the school nurse by the parent/guardian.
• Epi-Pen prescriptions must be replaced when they expire.

Anaphylaxis Emergency Care Plan

Epi-Pen Administration Form