AUTHORIZATION, WAIVER AND RELEASE
I authorize the City of Kingsburg employees to perform emergency procedures, including assisting with the
administration of Epi-Pens, injections or self-administered medications (whether over the counter or
prescription) or any other steps that I have described above to treat any illness, medical condition, allergic
reaction, or injury that my dependant may experience.
gnize and acknowledge that there are certain risks of injury in connection with administration of
medication to any minor child or dependent. Such risks include, but not limited to, failing to properly
administer the medication, failing to observe side effects, failing to assess and recognize an adverse
reaction, failing to assess and/or recognize a medical emergency, and failing to recognize the need to
summon emergency medical services.
by authorize the City of Kingsburg employees to assist in the administration of medication on my
behalf or allow my dependent to self-administer (if permitted by me dependents physician) the lawfully
prescribed Epi-Pen or other medications in the event of an allergic reaction by my dependent.
I acknowledge the assistance in the administration of the Epi-Pen or other medication to my dependent by
an individual who is not a nurse or medical professional may be necessary, and I specifically consent to
such practice. I hereby waive any claim for myself, my heirs, executors, assigns or personal representatives
that I may have against the City of Kingsburg, its officials, officers, employees, agents or volunteers, from
any and all claims for damages arising out of or in any way connected to the self-administration, assist-in-
administration or failure to administer or attempt to administer any medication to my dependent. I further
agree to protect, indemnify, defend and hold harmless the City of Kingsburg, its officers, employees, agents
and volunteers, for any claims for damages, including attorney fees, arising out of or in any way connected
to the self-administration, assist-in administration, failure to administer or attempt to administer medication
to my dependent.
give my permission to the City of Kingsburg staff to contact emergency services or obtain
emergency medical treatment if necessary. I agree to be wholly responsible to payment of any and all
medical and emergency services rendered to my dependent.
Signature of Parent/Guardian Date
Printed name Relationship
Participants are responsible for arriving at the program with all necessary medications, supplies, pumps,
backup medications, and any other equipment necessary for the participant to safely self-administer their
Medical monitoring of blood sugar levels must be done by parents or guardians prior to attending the
program each day, to ensure that they are within their target range.
Staff will not be responsible for identifying symptoms of hyperglycemia or hypoglycemia, but can assist
the participant in checking blood sugar levels with proper training provided by parents or guardians.
Parents/guardians are responsible for providing all necessary information regarding dietary restrictions,
food allergies or special diet considerations to staff.
Participants and parents/guardians shall be advised and reminded that it is the participant's responsibility
to administer the medication and that staff will only assist as needed. Staff will not give scheduled
It is the responsibility of the parent/guardian to pick up any medication that remains at the conclusion of
the program. Any medication not picked up will be disposed of in a safe manner.