Revised January 2021 Archdiocese of Galveston-Houston | Catholic Schools Office, 2021-2022 99b
INDIVIDUALIZED HEALTH CARE PLAN FOR STUDENTS WITH
FOOD & LIFE-THREATENING ALLERGIES
2021-2022 SCHOOL YEAR
To be completed by the Parent:
Student Name: Grade:
Allergies to:
Student needs to avoid:
Reaction(s) student has:
Self-Carry permission from physician: NO YES *
*If YES, parent will complete Self-Carry and Self-Administer Epinephrine Auto-Injector agreement.
PARENT/GUARDIAN:_______________________________
PHONE:___________________________________________
DOCTOR: _________________________________________
PHONE:___________________________________________
NAME:___________________________________________
PHONE:__________________________________________
NAME:___________________________________________
PHONE:__________________________________________
_______________________________ (Student Name) has severe allergies as mentioned above and in the Individualized
Health Care Plan from the physician. I have provided to the school the physician’s medication permission and instructions.
I am requesting these instructions be carried out by the school. I have instructed my child about his/her allergy and how to
avoid exposure to the allergen, care to take if exposure occurs and to tell an adult immediately if they have come in contact
with the allergen or are having a reaction. I will provide the medication with a proper pharmacy label and be aware of the
expiration date to replace the medication. I hereby request the medication specified by the physician be given to the above
named student, and it may be administered by medical or non-medical personnel. I understand 911 is called with the use of
Epinephrine.
Such agreement by the school is adequate consideration of my agreements contained herein. In consideration for the school
agreeing to allow the medication to be given to the student as requested herein, I agree to indemnify and hold harmless the
Archdiocese of Galveston-Houston, its servants, agents, any employees, including, but not limited to the parish, the school,
the principal, and the individuals giving the medication, of and from any and all claims, demands, or causes of action arising
out of or in any way connected with the giving of the medication or failing to give the medication to the student. Further, for
said consideration, I, on behalf of myself and the other parent of the student, hereby release and waive any and all claims,
demands, or causes of action against the Archdiocese of Galveston-Houston, its agents, servants, or employees, including,
but not limited to the parish, the school, the principal, and the individual giving or failing to give the medication. It is
mutually understood that the Archdiocese and its employees and affiliates are immune, pursuant to Tex. Educ. Code
§38.215, from suit resulting from any act or failure to act concerning the administration of epinephrine medication under the
individualized health care plan for food and life threatening allergies. Nothing within this Agreement shall be interpreted to
waive this immunity.
Parent Signature: Date:
To be completed by School:
School Nurse/Health Coordinator Signature: Date:
Principal Signature: Date:
Before & After Program Coordinator Signature: Date:
(If applicable)
Teacher notification provided by: Date:
School staff may be notified of the student’s health condition and the treatment plan in case of an emergency.
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