Permission to Administer an EpiPen Form

Permission to Administer an EpiPen

Disclaimer

Dynamyx Gymnastics Clubs including their employees, directors, volunteers (hereafter referred to as“Dynamyx”) are not responsible for any death, injury, loss or damage of any kind suffered by any person who is administered an EpiPen.

Description of Risks

Anaphylaxis or anaphylactic shock is a systemic immediate hypersensitivity reaction caused by such triggers as foods, medications, insect venom, or latex. The classic symptoms hives, swelling around the eyes or mouth, and difficulty breathing or swallowing. Anaphylaxis, or anaphylactic shock, is a systemic allergic reaction that can be fatal within minutes, either through swelling that shuts off airways or through a dramatic drop in blood pressure. An EpiPen is a fast-acting epinephrine injector that could save the life of someone who is experiencing an anaphylactic reaction.

Release of Liability and Indemnification

I AGREE TO BE SOLELY RESPONSIBLE for any death, injury, loss, or damage that my child may sustain from the administration of any EpiPen. I further agree to release, forever discharge, and agree to indemnify and hold harmless “Dynamyx” from and against liability for any and all claims, demands, actions, and costs which might arise out of the administration of an Epi Pen to my child even though such claims, demands,actions and costs which may have been caused by the negligence of “the Club” Acknowledgement.

I ACKNOWLEDGE THAT I HAVE READ the above Disclaimer, Description of Risks and Release and Indemnification. I also acknowledge that I understand, appreciate, and accept the risks associated with the administration of an EpiPen to my child and that I have executed this permission voluntary on behalf of my child.

Permission