Crosspoint Clubhouse
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- Samantha Gordon
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1 Crosspoint Clubhouse To the Parents/Guardians of The health and safety of our students is a priority for our school. Because your child has a life threatening allergy that may require the use of an Epinephrine Auto Injector (Epi-Pen) or a diatary restriction, a policy/procedures guideline has been implemented. You will find the policy/procedures guideline attached to this letter. In addition to the policy/procedures guideline, there are several forms that will require your signature and one that requires a physician s signature. Please understand that these measures are to protect your child. All the required forms must be completed and returned to the Clubhouse Office before your child may enter/return to school. Thank you very much for your cooperation and understanding regarding this policy/procedures guideline. Sincerely, Judy L. Sparkman Judy L. Sparkman Director 2101 Stonebridge Drive McKinney, TX (972) Fax: (972) clubhouse@crosspoint-church.org
2 CROSSPOINT CLUBHOUSE MOTHERS DAY OUT AND PRESCHOOL POLICY REGARDING EPINEPHRINE AUTO INJECTOR Students with Food Allergies For the safety of students with food allergies, Crosspoint Clubhouse Mothers Day Out and Preschool requires the parents/guardians to provide all lunches, snacks and food for parties. During class parties, the parent/guardian of students with food allergies may attend the party and select items their child may eat from the food selection at the classroom party. Teachers will not be allowed to select food items from the food selection at classroom parties. Parents/guardians may not send items in lunches or snacks that contain foods to which the student has an allergy. If the food allergy is air born or reaction by contact as well as ingestion, parents/guardians must make Crosspoint Clubhouse Mothers Day Out and Preschool aware of this situation so that special seating or restrictions may be implemented. Administering Epi-Pen Crosspoint Clubhouse Mothers Day Out and Preschool shall not be responsible for the diagnosis and treatment of student illness. The administration of an epi-pen to a student during school hours will be permitted only when failure to take such medicine would jeopardize the health of the student. Before an epi-pen may be administered to any student during school hours, Crosspoint Clubhouse Mothers Day Out and Preschool shall require the written request of the parent/guardian that shall give permission for such administration and relieve the school and its employees of liability for administration of medication. In addition, Crosspoint Clubhouse Mothers Day Out and Preschool requires the written order of the prescribing physician that shall include: A. The purpose of the medication; B. The dosage; C. The time at which or the special circumstances under which medication shall be administered; D. The length of time for which medication is prescribed; E. The possible side effects of the medication. Both documents, the Authorization for Epi-Pen Administration and the Parental/Guardian signed Agreement, shall be kept on file in the Crosspoint Clubhouse Mothers Day Out and Preschool office. Emergency Administration of Epinephrine Crosspoint Clubhouse Mothers Day Out and Preschool shall permit the classroom teachers or directors to administer epinephrine via epipen in emergency situations. The teachers and directors must be properly trained in the administration of the epi-pen. Crosspoint Clubhouse Mothers Day Out and Preschool shall inform the student s parents/guardians in writing that if the specified procedures are followed, Crosspoint Clubhouse Mothers Day Out and Preschool, its employees and agents shall have no liability as a result of any injury arising from the administration of the epi-pen to the student. Parents/guardians shall provide Crosspoint Clubhouse Mothers Day Out and Preschool with the following: A. Written orders from the physician that the student requires the administration of epinephrine for anaphylaxis and does not have the capability for self-administration of the medication; B. Written permission for the administration of epinephrine via epi-pen by classroom teachers or directors. C. A Signed statement acknowledging their understanding that if the specified procedures are followed, Crosspoint Clubhouse Mothers Day Out and Preschool shall have no liability as a result of any injury arising from the administration of the epi-pen by the classroom teachers or directors to the student and that Crosspoint Clubhouse Mothers Day Out and Preschool, its employees, and agents shall be indemnified and held harmless against any claims arising out of the administration of the epi-pen to the student. Permission for the administration of epinephrine via epi-pen shall be granted annually and must be renewed each school year upon the fulfillment of the above requirements. Keep this Page for Your Records
3 CROSSPOINT CLUBHOUSE MOTHERS DAY OUT AND PRESCHOOL PARENT ACKNOWLEDGEMENT Epinephrine Auto Injector EPI-PEN I have read a copy of the Crosspoint Clubhouse Parent Handbook and I have read the Crosspoint Clubhouse Mothers Day Out and Preschool Policy regarding the administration of Epinephrine (Epi-Pen) in school. Crosspoint Clubhouse Mothers Day Out and Preschool shall have no liability as a result of any injury arising from the administration of a pre-filled, single dose auto injector mechanism containing epinephrine and that I shall indemnify and hold harmless Crosspoint Clubhouse Mothers Day Out and Preschool, its employees or agents against any claims arising out of the administration of a pre-filled, single dose auto injector containing epinephrine to my child. I will be responsible for obtaining the prescription and the signed consent from my child s physician and for providing Crosspoint Clubhouse Mothers Day Out and Preschool with an appropriate amount of Epinephrine Auto Injectors and for replacing any expired Epinephrine Auto Injector on a timely basis. I understand that this entire consent must be renewed annually. Parent s/guardian s Signature Return this page to the Clubhouse Office
4 CROSSPOINT CLUBHOUSE MOTHERS DAY OUT AND PRESCHOOL AUTHORIZATION FOR EPI-PEN ADMINISTRATION : is being treated for It may be necessary that he/she receive the following Emergency medication in school: Dose to be given from to This medication is to be given immediately if any of the following symptoms occur. The child is then to be transported to the nearest Emergency Room via ambulance. Any adverse reactions to be expected Doctor s Signature Yes No I authorize Crosspoint Clubhouse Mothers Day Out and Preschool classroom teachers and directors to administer the above prescribed medication (Epi-Pen). Parent s/guardian s Signature Return this page to the Clubhouse Office
5 Texas Dept. of Protective and Regulatory Services FORM 2904 November 1996 AUTHORIZATION FOR EMERGENCY MEDICAL CARE If I cannot be reached to make arrangements for emergency medical care for my child at the time of an illness or accident, I give my permission for: Crosspoint Clubhouse Mother s Day Out and Preschool 2101 S. Stonebridge Drive McKinney, TX To take my child : Name of Child: To Name of Doctor: Telephone No.: Address of Doctor: Or to/ o a: Name of Hospital or Clinic: Telephone No.: Address of Hospital or Clinic: I give consent for necessary emergency treatment when my child is in the care of this physician or hospital or clini Signature of Parent or Legal Guardian Return this page to the Clubhouse Office
6 Texas Dept of Family and Protective Services AUTHORIZATION FOR DISPENSING MEDICATION Form 7238 May 2005 PARENT S AUTHORIZATION Name of Child to Receive Medicine Name of Medication Prescribing Physician Prescription No. Expiration Dosage When to Give Continue Medication Until (date) NOTE: Medication must be in its original container and labeled with your child s name and the date medication is left at the facility. Medication can only be administered in amounts according to the label directions. Signature-Parent or Guardian CAREGIVER S RECORD OF ADMINISTERING MEDICATION CHILD S NAME NAME OF MEDICATION DATE GIVEN TIME GIVEN AMOUNT GIVEN FULL NAME OF CAREGIVER OR EMPLOYEE Disposition of Left-over Medication Returned to Child s Parent/Guardian Thrown Away : Return This Page to the Clubhouse Office
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