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D-Xperience Medical/Allergy Release

 Waiver Form



D-Xperience plan of action for allergic reaction or medical emergency:


-CALL 911, Immediately:

-Administer (If provided) Epinephrine Auto-Injector (retractable devices preferred) intramuscularly into the anterolateral of thigh for the following symptoms: 

Shortness of breath, wheezing, or coughing, pale or bluish skin color, weak pulse, many hives or redness over body, fainting or dizziness, tight or hoarse throat, trouble breathing or swallowing, lip or tongue swelling that bothers breathing, vomiting or diarrhea (if severe or combined with other symptoms), feeling of doom, confusion, altered consciousness or agitation 



My child has a severe allergy to an insect sting or the following food(s):_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 


OTHER MEDICATION AND MEDICAL CONCERNS (e.g., inhaler/bronchodilator if child has asthma):___________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I understand that upon administering medication we will immediately contact parent/guardian or emergency contact  and they will be required to pick up their child at the time of call.

I must give D-Xperience my child’s medicine and equipment. I will try to give the D-Xperience epinephrine pens with retractable needles. 

All prescriptions I give D-Xperience must be new, unopened, and in the original bottle or box. I will get another medicine for my child to use when he or she is not in school or is on a school trip. Prescription medicine must have the original pharmacy label on the box or bottle. Label must include: 1) my child’s name, 2) pharmacy name and phone number, 3) my child’s health care practitioner’s name, 4) date, 5) number of refills, 6) name of medicine, 7) dosage, 8) when to take the medicine, 9) how to take the medicine and 10) any other directions. 

Any other Non-life saving medicines other than Inhaler or Epi pen must be given to child prior to coming to D-Xpereince. Parent, Guardian or authorized person is able to come by the site to administer to child.
Child’s Full Name: _______________________________________________________________ 


Authorized person’s name other than Parent/ Guardian:________________________________________________________________________


Parent/Guardian Full Name:_______________________________________________________


Parent/ Guardian Signature:__________________________________Date:_________________


Director’s Signature:_________________________________________Date:_________________


1366 Startown Rd

Lincolnton, NC 28092

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