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Anaphylaxis Allergies and Epi-Pen Consent Form

Child's name

Child's Date of Birth (MM/DD/YYYY)

Please upload a photo of your child.

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Email Address

Contact information

Parent/Guardian (1) name

Phone number

Alt. phone number

Parent/Guardian (2) name

Phone number

Alt. phone number

Emergency contact name - other than Parent/Guardian(s) listed above

Phone number

Alt. phone number

Allergy Details

The key to preventing an Anaphylactic Emergency is absolute avoidance of the allergen.

Please list any life-threatening allergies.

Anaphylactic Allergies and the Administration of Epi-Pens Procedure.

Participants or their parents/guardians must notify the Community Services Department upon registering for programs if they require the use of an Epi-Pen.

Participants who require Epi-Pens are responsible to ensure that they have their Epi-Pens with them while attending the program. Epi-Pens must be carried by the participants, in a waist pack that is easily identifiable. The Municipality of Clarington does not supply Epi-Pens.

Recreation Program Staff will supervise only, the self-administration of Epi-Pens by participants.

In the event that a participant is not capable of administering the Epi-PEn themselves, Recreation Program Staff will administer the Epi-Pen using the hand over hand technique.

Participants must provide consent allowing staff to assist in administering an Epi-Pen, signed by a parent or legal guardian.

Recreation Program Staff will be required to have Epi-Pen training.

Consent Statements

I have read and understood that the personal information and photo on collected in this form may be posted or made available to staff in case of an emergency. Personal information contained on this form is collected under the authority of the Municipal Act, and will be used by the staff in case of an emergency.

I give the Recreation Program Staff permission to administer an Epi-Pen to my child in the event that they are unable to administer the Epi-Pen themselves.

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Anaphylaxis Allergies and Epi-Pen Consent Form

Contact information

Allergy Details

Anaphylactic Allergies and the Administration of Epi-Pens Procedure.