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Epinephrine Auto Injector Policy and Consent Form

    • Carnegie Museums of Pittsburgh personnel, including employees, staff, security personnel and volunteers, are not professional medical personnel.
    • We do not provide Epinephrine Auto Injectors. They must be prescribed by a physician for a specific child and brought to camp at one of the Carnegie Museums of Pittsburgh, by a parent, each time the child is in attendance. The camper will be expected to carry their Epinephrine Auto Injector with them throughout the day, campers may bring a small backpack for this purpose. Carnegie Museums of Pittsburgh personnel are not permitted to carry the Epinephrine Auto Injector for the camper.
    • If a child requires the possible use of an Epinephrine Auto Injector it should be indicated on the summer camp permission form and signed by the parent/legal guardian.
    • Epinephrine Auto Injector must be properly and clearly labeled with:
      1. the child’s first and last name;
      2. the dosage of Epinephrine; and
      3. the expiration date (We will not accept expired Epinephrine Auto Injectors).
    • Carnegie Museums of Pittsburgh personnel will only administer an Epinephrine Auto Injector in the event of an emergency where the child is unable to self administer. In such event, Carnegie Museums of Pittsburgh personnel will administer the Epinephrine Auto Injector in accordance with this Policy provided that the child’s parent/guardian previously provided permission by signing below.
    • If an Epinephrine Auto Injector is administered, 911 and the parent/guardian of the camper will be notified.
  • I hereby acknowledge that I am primarily responsible for administering medication to my child/minor for whom I am legally responsible. However, in my absence, I hereby authorize my child/minor for whom I am legally responsible to administer the above described medication(s) to him/herself. I also authorize Carnegie Museums of Pittsburgh personnel to administer medication in the event of an emergency as set forth above. I, for myself and my child/minor for whom I am legally responsible and our heirs, next of kin, executors, assigns and insurers, hereby irrevocably and unconditionally release, waive and covenant not to sue and agree to indemnify and hold harmless Carnegie Institute d/b/a Carnegie Museums of Pittsburgh (the “Museum”) and its employees, volunteers, staff and all others acting with or for the Museum, from and against any and all claims, causes of action, losses, costs (including legal fees), damages and liabilities for any and all injuries or other types of harm arising out of or relating to the administration of said medication(s) to my child/minor for whom I am legally responsible while participating in Carnegie Museums of Pittsburgh Summer Camp and any and all associated programming. I represent that I am over 18 years of age and have full authority to enter into this Waiver of Liability. Pennsylvania law shall apply to this Waiver of Liability and jurisdiction and venue for all controversies or claims relating to this Waiver of Liability or the said administration of medication shall be Allegheny County, Pennsylvania.

  • I agree to the conditions and waiver of liability above and I give permission to Carnegie Museums of Pittsburgh personnel to administer my child’s,
  • Child’s Name * Required
  • ’s, prescribed Epinephrine Auto Injector in case of an emergency.
  • Name of Parent/Guardian * Required
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.