JHCCB-E-2: Strategies in Prevention and Management of Anaphylaxis in the School Setting

Classification: 
J: Students
Code: 
JHCCB-E-2

APPENDIX A2

 PARENT(S) / GUARDIAN(S) CONSENT FORM

 

I __________________________________ authorize the Vancouver School Board to display

(name of parent(s)/guardian(s)

a picture of _______________________________________and identify that this is a person with

                        (name of student)

____________________________________________.  I understand that this display will be in

 (nature of condition/risk factor)

________________________________ and may be in places within the school, such as entrance

      (name of school)

ways to classrooms, staffroom, and office. It is understood that the reason for this display is to enable Vancouver School Board personnel and its agents  to be better able to respond to potential emergencies. This authorization is valid from the date signed until revoked.

 

___________________________________            ____________________________________

(Date signed)                                             (Signature of Parent(s)/Guardian(s)       

 

___________________________________           _____________________________________

(Date Signed)                                            (Signature of Witness)

 

PARENT AGREEMENT:

I/we __________________________ acknowledge my/our participation in the development of this Emergency Action Plan and agree to execute reliably the parent(s)’ / guardian(s)’ commitments listed within them. I also acknowledge that my/our failure to do so may result in the cancellation or non-implementation of the emergency action plan.

I also give my consent for the staff of the Vancouver School Board and its agents and without limiting the generality of the foregoing the staff of ____________________ School to execute the school’s commitments as outlined within this plan.  In the event of an emergency, I authorize the Vancouver School Board staff, including the staff of _________________________ School to administer the designated medication and obtain suitable medical assistance.  I agree to assume all costs associated with medical treatment and absolve the Vancouver School Board and its employees of responsibility for any adverse reactions resulting from administration of the medication.

 

_______________________________              ________________________________________

(Date signed)                                          (Signature of Parent(s)/Guardian(s)        

 

______________________________               ________________________________________

(Date Signed)                                        (Signature of Witness)