2023/24 Emergency Medication Consent Form - Holy Redeemer Catholic Parish

23-24 Emergency Medication Consent Form

Emergency Medication Consent Form

According to Missouri State Statute Section 167.630, RSMo and 167.0635.1, RSMo schools are able
to obtain and maintain an adequate supply of epinephrine pre-filled auto-injector and asthma-related rescue medications for emergency use by the employed school nurse licensed under chapter 335.

The school nurse or another employee trained and supervised by the employed school nurse may administer these medications when they believe, based on training, that a student is having a life-threatening anaphylactic reaction or life-threatening asthma episode.

The St. Louis Archdiocese has adopted a policy on Emergency Stock Medications.

We have decided to stock Emergency Epinephrine and/or Albuterol for those students with no known history of anaphylaxis or asthma.

(If your child has a known/documented anaphylaxis allergy and/or asthma, rescue medication
needs to be provided by the family, along with an action plan to the school.)

CONSENT
Parental approval to use standing physician ordered medications allows for efficient treatment of students emergency health issue.

I give my permission for the nurse or trained designee to administer appropriate standing physician ordered emergency medications for my child(ren):

Yes

Family Name

Child 1

Child 1 DOB

Child 2

Child 2 DOB

Child 3

Child 3 DOB

Child 4

Child 4 DOB

Parent/Guardian Signature

Clear

Parent/Guardian Name

Date

If you are human, leave this field blank.