Cut Bank School District

DESIGNATION AND ACCEPTANCE TO ADMINISTER GLUCAGON

 

 

 

As a parent, an 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. 

 

___________________________                      ________________________

Signature                                        Date

 

 

 

As the parent-designated adult, I agree to administer glucagon in emergency situations to ___________________.  I understand the glucagon must be provided by the parent, an individual who has 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___.

 

____________________________________                  _________________________

Signature of parent-designated adult                  Date