Please have physician complete this action plan if your child has a severe allergy requiring an Epi-Pen. In addition to this form, have physician complete a Medication administration Form for EACH medication on that plan (ie. Benadryl and Epi). 

This form needs to be completed by the physician and signed by both the physician and the parent/guardian in order for an antihistamine, such as Benadryl, to be given in school.

Physician must complete this order form and both parent/guardian and physician must sign it in order to Epinephrine to be given in the school.