4.35F3—Glucagon AND/OR INSULIN ADMINISTRATION CONSENT FORM Student’s Name (Please Print) This form is good for school year __________. This consent form must be updated anytime the student's medication order changes and renewed each year and/or anytime a student changes schools. The school has developed an individual health plan (IHP) acknowledging that my child has been diagnosed as suffering from diabetes. The IHP authorizes the school nurse to administer Glucagon or insulin to my child in an emergency situation. In the absence of the nurse, trained volunteer district personnel may administer to my child in an emergency situation: Glucagon ______ Insulin ______ I hereby authorize the school nurse to administer Glucagon and insulin to my child, or, in the absence of the nurse, trained volunteer district personnel designated as care providers, to administer the medication(s) I selected above to my child in an emergency situation. I will supply the medication(s) I selected above to the school nurse in the original container properly labeled with the student’s name, the ordering provider’s name, the name of the medication, the dosage, frequency, and instructions for the administration of the medication (including times). Additional information accompanying the medication shall state the purpose for the medication, possible side effects, and any other pertinent instructions (such as special storage requirements) or warnings. I acknowledge that the District, its Board of Directors, its employees, or an agent of the District, including a healthcare professional who trained volunteer school personnel designated as care
4.35F3—Glucagon AND/OR INSULIN ADMINISTRATION CONSENT FORM Student’s Name (Please Print) This form is good for school year __________. This consent form must be updated anytime the student's medication order changes and renewed each year and/or anytime a student changes schools. The school has developed an individual health plan (IHP) acknowledging that my child has been diagnosed as suffering from diabetes. The IHP authorizes the school nurse to administer Glucagon or insulin to my child in an emergency situation. In the absence of the nurse, trained volunteer district personnel may administer to my child in an emergency situation: Glucagon ______ Insulin ______ I hereby authorize the school nurse to administer Glucagon and insulin to my child, or, in the absence of the nurse, trained volunteer district personnel designated as care providers, to administer the medication(s) I selected above to my child in an emergency situation. I will supply the medication(s) I selected above to the school nurse in the original container properly labeled with the student’s name, the ordering provider’s name, the name of the medication, the dosage, frequency, and instructions for the administration of the medication (including times). Additional information accompanying the medication shall state the purpose for the medication, possible side effects, and any other pertinent instructions (such as special storage requirements) or warnings. I acknowledge that the District, its Board of Directors, its employees, or an agent of the District, including a healthcare professional who trained volunteer school personnel designated as care