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EpiPen® ADMINISTRATION PERMISSION FORM

I hereby authorize the staff, volunteers, and agents at BeachSports / PCH Skate Camps to administer an EpiPen® to my child if he or she has known exposure and/or a severe allergic reaction. I agree to release, indemnify, and hold harmless BeachSports, PCH Skate Camp, Sports Camp Management, LLC, and any of its staff, volunteers, or agents from lawsuit, claim, expense, demand, or action against them for administering the EpiPen® provided they administer the EpiPen® prescribed specifically for my child. I am aware that the injection probably will be administered by a staff member, volunteer, or agent who is not a healthcare professional. I understand that I will always be notified as quickly as possible anytime an EpiPen® has been administered to my child.

Furthermore, BeachSports/PCH Skate Camp and any of its staff, volunteers, or agents are not responsible for the damage, loss or theft of the EpiPen while in their possession.

The undersigned parent or guardian of Participant hereby covenants, warrants, represents and agrees that he or she is executing this Agreement on behalf of, and as an agent for, any other individual who may be a parent or guardian of Participant, and that by executing this Agreement, the undersigned is binding himself/herself, Participant, and any other parent or guardian of Participant and all of their heirs, executors, personal representatives, assigns and estates to this Release.

Today's Date: July 4, 2020

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

My child is allergic to:

The following EpiPen has been prescribed. (Check as appropriate) *
EpiPen® (the premeasured dose is 0.3 mg of Epinephrine)
EpiPen® Jr (the premeasured dose is 0.15 mg of Epinephrine)
My child has received adequate training on how and when to use an EpiPen® and can use it properly in case of emergency. He or she will carry an EpiPen® at all times.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

My child is allergic to:

The following EpiPen has been prescribed. (Check as appropriate) *
EpiPen® (the premeasured dose is 0.3 mg of Epinephrine)
EpiPen® Jr (the premeasured dose is 0.15 mg of Epinephrine)
My child has received adequate training on how and when to use an EpiPen® and can use it properly in case of emergency. He or she will carry an EpiPen® at all times.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

My child is allergic to:

The following EpiPen has been prescribed. (Check as appropriate) *
EpiPen® (the premeasured dose is 0.3 mg of Epinephrine)
EpiPen® Jr (the premeasured dose is 0.15 mg of Epinephrine)
My child has received adequate training on how and when to use an EpiPen® and can use it properly in case of emergency. He or she will carry an EpiPen® at all times.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

My child is allergic to:

The following EpiPen has been prescribed. (Check as appropriate) *
EpiPen® (the premeasured dose is 0.3 mg of Epinephrine)
EpiPen® Jr (the premeasured dose is 0.15 mg of Epinephrine)
My child has received adequate training on how and when to use an EpiPen® and can use it properly in case of emergency. He or she will carry an EpiPen® at all times.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

My child is allergic to:

The following EpiPen has been prescribed. (Check as appropriate) *
EpiPen® (the premeasured dose is 0.3 mg of Epinephrine)
EpiPen® Jr (the premeasured dose is 0.15 mg of Epinephrine)
My child has received adequate training on how and when to use an EpiPen® and can use it properly in case of emergency. He or she will carry an EpiPen® at all times.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

My child is allergic to:

The following EpiPen has been prescribed. (Check as appropriate) *
EpiPen® (the premeasured dose is 0.3 mg of Epinephrine)
EpiPen® Jr (the premeasured dose is 0.15 mg of Epinephrine)
My child has received adequate training on how and when to use an EpiPen® and can use it properly in case of emergency. He or she will carry an EpiPen® at all times.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

My child is allergic to:

The following EpiPen has been prescribed. (Check as appropriate) *
EpiPen® (the premeasured dose is 0.3 mg of Epinephrine)
EpiPen® Jr (the premeasured dose is 0.15 mg of Epinephrine)
My child has received adequate training on how and when to use an EpiPen® and can use it properly in case of emergency. He or she will carry an EpiPen® at all times.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

My child is allergic to:

The following EpiPen has been prescribed. (Check as appropriate) *
EpiPen® (the premeasured dose is 0.3 mg of Epinephrine)
EpiPen® Jr (the premeasured dose is 0.15 mg of Epinephrine)
My child has received adequate training on how and when to use an EpiPen® and can use it properly in case of emergency. He or she will carry an EpiPen® at all times.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

My child is allergic to:

The following EpiPen has been prescribed. (Check as appropriate) *
EpiPen® (the premeasured dose is 0.3 mg of Epinephrine)
EpiPen® Jr (the premeasured dose is 0.15 mg of Epinephrine)
My child has received adequate training on how and when to use an EpiPen® and can use it properly in case of emergency. He or she will carry an EpiPen® at all times.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

My child is allergic to:

The following EpiPen has been prescribed. (Check as appropriate) *
EpiPen® (the premeasured dose is 0.3 mg of Epinephrine)
EpiPen® Jr (the premeasured dose is 0.15 mg of Epinephrine)
My child has received adequate training on how and when to use an EpiPen® and can use it properly in case of emergency. He or she will carry an EpiPen® at all times.
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

My child is allergic to:

The following EpiPen has been prescribed. (Check as appropriate) *
EpiPen® (the premeasured dose is 0.3 mg of Epinephrine)
EpiPen® Jr (the premeasured dose is 0.15 mg of Epinephrine)
My child has received adequate training on how and when to use an EpiPen® and can use it properly in case of emergency. He or she will carry an EpiPen® at all times.
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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