3416F
Administration of Glucagon

School employees may voluntarily agree to administer glucagon to a student pursuant to § 20-5-412,MCA, only under the following conditions: (1) the employee may administer glucagon to a diabetic student only in an emergency situation: (2) the employee has filed the necessary designation and acceptance documentation with the District, as required by § 20-5 - 412(2), MCA, and (3) employee has filed the necessary written documentation of training with the District, as required by § 20-5-412(4), MCA.

DESIGNATION AND ACCEPTANCE TO ADMINISTER GLUCAGON

As a parent/individual who has executed a caretaker relative educational authorization affidavit, an individual who has executed a caretaker relative medical authorization affidavit, or a guardian of a diabetic student, I have designated________________________________to administer glucagon to _____________________________only in emergency situations. I understand the designee must be an adult.

As the parent-designated adult, I agree to administer glucagon in emergency situations to ________________________. I understand the glucagon must be provided by the parent/ individual who have executed a caretaker relative educational authorization affidavit, an individual who has executed a caretaker relative medical authorization affidavit, or the guardian of the student. I confirm that I have been trained in recognizing hypoglycemia and the proper method of administering glucagon. I have been trained by___________________________________on the _______day of __________________, 20___

Consent for Mutual Exchange of Information

I hereby authorize the mutual exchange of information regarding this student between Butte School District # 1 and the below named Health Care Provider/Medical Clinic. I certify that I am the parent or legal guardian of the above named child or that I am the student of a majority age and have the authority to sign this release.
 

Student Name: _____________________________  Date of Birth: _______________

Health Care Provider/Medical Clinic Name: ________________________        Phone: ______________