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This form is to be completed by the healthcare provider when a student requires emergency medication for an allergic reaction and/or this form is to be completed by the parent/guardian indicating whether or not the student is capable of self-administering emergency medication. This form also has a section for parents/guardians to authorize a trained designee to administer emergency medication in the absence of the school nurse. Parents, please sign the form.

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*Food Allergy & Anaphylaxis Emergency Care Plan