WAIVER OF EMERGENCY RESPONSE TO LIFE THREATENING ASTHMA OR SYSTEMIC ALLERGIC REACTIONS PROTOCOL
__________________ School District
Student Name:__________________________________
Date of Birth: __________________
School: ________________________________________
Grade: ________________________
I am aware of the school policy that provides a protocol to follow by school personnel to administer EpiPen/albuterol to a student when it is determined that the student is suffering a life threatening asthma or systemic allergic reaction while school is in session.
After considering the school policy and the best interests of my child, ___________________, I do not wish to have him/her administered albuterol or medication from an Epi-Pen by school personnel under any circumstances for the 20___ - 20___ school year.
___________________________________________
(Signature of Parent/Legal Guardian/Custodian of Child)
___ ___________________________
(Date)
