Emergency Care for the Management of a Student With a Diagnosis of Anaphylaxis

Release and Indemnification Agreement for Epinephrine Auto Injector

I hereby request and authorize Montgomery County Public Schools (MCPS) and Montgomery County Department of Health and Human Services (DHHS) personnel to administer an epinephrine auto-injector as directed by the authorized prescriber (Part II, below). I agree to release, indemnify, and hold harmless MCPS and DHHS and any of their officers, staff members, or agents from lawsuit, claim, demand, or action against them for administering prescribed medication to this student, provided MCPS and DHHS staff are following the authorized prescriber’s orders as written in Part II. I am aware that the injection may be administered by a trained, unlicensed staff member. I have read the procedures outlined on the back of this form and assume the responsibilities as required.

I understand that the rescue squad (911) will always be called when an epinephrine auto-injector is administered, whether or not the student manifests any symptoms of anaphylaxis

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