Download FORM 2 - County of Union, New Jersey

UNION COUNTY YOUTH PROGRAM(S) – PARENTS/GUARDIANS’
AUTHORIZATION AND RELEASE FORM FOR THE ADMINISTRATION OF
EPIPEN(S) AND INHALER(S)
Child’s Name:_______________________________
Date of Birth:___________________
Parents/guardians requesting EpiPen(s) and/or inhaler(s) administration to their child
during the program must provide the County of Union with appropriate written
authorization by the child’s physician as well as completion of the within form.
EpiPen(s) and/or inhaler(s) must be stored in its original container and labeled
properly before any EpiPen(s) and/or inhaler(s) is administered. Please refer to the
attached Guidelines for Administering Medication for Union County Youth Program(s).
I,_____________________, authorize my child to self-administer his/her EpiPen(s)
and/or inhaler(s). I have provided the County of Union with written orders from the
physician that my child is capable of administering his/her EpiPen(s) and/or inhaler(s).
I, _____________________, authorize the County of Union, the registered nurse and
his/her designees and EMT, on my behalf and in my stead, to administer to my child
his/her EpiPen(s) and/or inhaler(s) in the event my child is unable to do so during
program hours.
Further, I ____________________, agree to waive any and all claims for damages I might
have against the County of Union, its officials, employees, volunteers, and/or agents,
arising out of the administration of said EpiPen(s) and/or inhaler(s). I agree to hold
harmless the County of Union, its officials, employees, volunteers, and/or agents, both
jointly and severally, from and against any and all claims, property damages, personal
injury incurred or resulting therefrom. I understand and agree that this waiver and
release is to be binding on my heirs and assigns.
_____________________________________________
Signature of parent/guardian
__________________________
Date
__________________________________________
Home Address
__________________________
Phone Number
____________________________________
City State Zip
__________________________
Cellular Number
Please Return To:
Union County Parks & Recreation
Watchung Stable♦ 1160 Summit Lane ♦ Mountainside ♦ New Jersey 07092-1409
908 789 3665 ♦ www.ucnj.org/parks-recreation/watchung-stable
FORM 2