Allergy & EpiPen Authorization Form

Child's Full Name

Date of Birth

Allergy Information

Does your child have any severe allergies? No Yes (Please specify below).

Known triggers (Foods, insects, medications, etc.):

EpiPen/Emergency Medication

Does your child require an EpiPen (epinephrine auto-injector)?

No Yes

If yes, the EpiPen must be provided by the parent/guardian.

Expiry Date:

Location of EpiPen during event:

Emergency Authorization

In the event of a severe allergic reaction, I authorize event staff/volunteers to administer the provided EpiPen to my child.

Yes, I give permission. No Option

I understand that while reasonable care will be taken, event staff may not be medically trained professionals.

Important Notice

Due to limited staffing and the absence of medically trained personnel, we are not able to provide one-on-one support for children with severe or high-risk medical needs at this time. Parents/guardians may be required to remain on-site if additional support is necessary.

Emergency Contact Information

Primary Contact Name

Phone

Secondary Contact Name

Phone

Medical Information

Family Doctor

Family Doctor Number

Consent & Signature

I confirm that the information provided is accurate and complete. I accept responsibility for ensuring my child’s medication is up to date and provided.

Parent/Guardian Name (As Signature):

Today's Date

Description

Please fill out this form and click submit.

Allergy & EpiPen Authorization Form

Description

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