Parent’s Authorization to Date: Parent’s Signature: Self Administer Yes No *TURN OVER FOR INSTRUCTIONS ON ADMINISTERING EPIPEN EPIPEN JR.* EMERGENCY FOR STUDENT NAME: ________________________________________GRADE: _______________________
Parent’s Signature: Parent’s Authorization to Self Administer Yes No Date: *TURN OVER FOR INSTRUCTIONS ON ADMINISTERING EPIPEN EPIPEN JR.* EMERGENCY FOR STUDENT NAME: ________________________________________GRADE: _______________________