MCLEAN BIBLE CHURCH, TYSONS CAMPUS - KID S QUEST HEALTH INFORMATION AND EPINEPHRINE INJECTOR ADMINISTRATION POLICIES AND PROCEDURES

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1 Overview: MCLEAN BIBLE CHURCH, TYSONS CAMPUS - KID S QUEST HEALTH INFORMATION AND EPINEPHRINE INJECTOR ADMINISTRATION POLICIES AND PROCEDURES Kid s Quest is dedicated to bringing church and family together for a child's spiritual growth. To do this, we must provide a safe environment for the children who attend our programming. One way we do this is to be aware of any medical problems a child may have, including allergies. We know that allergies are caused by various sources such as certain foods (peanuts, tree nuts, milk, wheat, etc.), animals, insect stings or bites, medication, environmental agents, latex, etc. and that reactions range from mild to severe. We also understand some children suffer from other health issues such as asthma or diabetes and could be affected by aspects of our program. To help us care for your child, we ask that you complete the attached Detailed Health Form. If your child has severe allergies that may require the administration of an epinephrine injector for an allergic reaction, we ask that you also complete and return the reverse side of the Detailed Health Form (Part 2), as well as a half-sheet Epinephrine Injector Administration Permission Form required to accompany your child s epinephrine injector in a zip lock bag. Allergy policies and forms can be obtained at check-in stations during weekend services, or on the Kid s Quest web site at mbctysons.org/kqallergy. If you have any questions or concerns, please contact Caitlin Davis at or kidsquest@mcleanbible.org. Snack Policies: 1. Kid s Quest strives to be a tree nut-free and peanut-free zone anytime Kid s Quest programming is in progress. The staff will do our due diligence to screen snacks we provide against a list of tree nut and peanut allergens and will do our best to screen any snacks brought by a parent/teacher. 2. The following are foods that are generally served: a. Infants through Crawlers no food is served, only parent-provided b. Walkers Cheerios (contains: wheat, corn) c. Hikers through Little Adventurers Animal crackers and pretzels (contains: wheat, soy, corn) d. Preschool - Pretzels (contains: wheat, corn) e. Kindergarten through First Grade at 12:30pm service only Pretzels (contains: wheat, corn) f. Fourth & Fifth Grade on first Sunday of month Popcorn (contains: salt, milk, soy, coconut/canola oil, food dyes) 3. Parents are welcome to bring snacks for their own child if he or she cannot have any of the above items, provided that the snack is in its original packaging with the ingredient list intact. 4. A list of ingredients for snacks will be available in supplied classroom bins for Nursery through Preschool classes, and in Elementary classes will be displayed in large group areas on days when snacks are being served. 5. Snack containers are washed between uses to prevent cross-contamination between different food products. 6. Outside snacks are sometimes brought in for special occasions. Parents are responsible for watching for any bright green Special Snack signs outside the classroom door or in large group areas. Whenever possible, original snack packaging for special snacks will be available so that parents may read the ingredient list. Health/Allergy Forms Information: 1. We encourage parents/guardians whose child has allergy or health concerns to submit a Detailed Health Form (Part 1). If the child has an epinephrine injector, please complete the reverse side (Part 2) of the Detailed Health Form. a. Forms can be obtained at check-in stations or on the Kid s Quest web site at mbctysons.org/kqallergy b. New Detailed Health Forms will be distributed at the start of each school year so we can update our records. c. A new Detailed Health Form may be submitted during the year if there is a change in the child s allergies and/or dosage or conditions under which the epinephrine injector is to be given. 2. A completed half-sheet Epinephrine Injector Administration Permission Form should be placed in a zip lock bag with each child s epinephrine injector. Epinephrine Injector Administration Permission Forms may be reused from week to week. 1

2 Epinephrine Injector Policies: 1. Kid s Quest staff and volunteers are not professional medical personnel. However, basic epinephrine injector administration training is offered for staff and key volunteer leaders. 2. We do not provide epinephrine injectors. They must be prescribed by a physician for a specific child and brought to Kid s Quest by a parent each time the child is in attendance. 3. If a child requires the possible use of an epinephrine injector, we must have the following: a. A Detailed Health Form completed on both sides and signed by the parent/legal guardian. b. Epinephrine injectors (preferably two) inside a zip lock bag including the completed half-sheet Epinephrine Injector Administration Permission Form. Epinephrine injectors must be properly and clearly labeled with: i. The child s first and last name ii. The dosage of Epinephrine iii. The expiration date (We will not accept expired epinephrine injector 4. Kid s Quest will not administer any medication except for an epinephrine injector in the event of an emergency. Procedures: 1. If your child has any health issues or allergies, pick up a green Allergy/Health Issues sticker at any Check-In Station (or at your child s classroom door for nursery - preschool). Complete the requested information and place the sticker on the back of your child to alert the staff and volunteers. If needed, feel free to use more than one sticker. 2. Inform the classroom door greeter about your child s health issues or allergies each time you take the child to class or an event. We strongly suggest that you attend the same service each week so staff and volunteers become familiar with your child s specific needs and can provide the best possible care for your child. 3. If your child may require the use of an epinephrine injector, place the epinephrine injectors (preferably two) into a zip lock bag with the completed half-sheet Epinephrine Injector Administration Permission Form which may be reused from week to week. a. The zip lock bag is to be hand-delivered to the teacher or adult in charge of the classroom or event unless the child is approved to carry his or her own epinephrine injector. b. Epinephrine injectors should be placed in the Emergency Bins by the classroom staff or volunteer. The Emergency Bins are located inside each small group classroom near a door and large group areas where they can be picked up by parent at the end of the service. A classroom greeter can show you the location of the bin for your child s specific classroom and/or age group. c. Should a child stay in the classroom for two services, a Kid s Quest Coordinator will be responsible for moving a child s epinephrine injector to his or her new location, if applicable. d. If your child has an anaphylactic reaction and has an epinephrine injector the following will be done: i. The epinephrine injectors in their respective zip lock bag will be retrieved from the Emergency Bin. ii. A Kid s Quest staff member or volunteer will check the half-sheet Epinephrine injector Administration Permission Form in the zip lock bag to determine parent permission and epinephrine injector dosage information. iii. An epinephrine injector will be administered by a Kid s Quest staff member or volunteer. iv. The Rescue Squad will be called by dialing 911. v. The parents or legal guardian will be called by LED number on their key tag or by cell phone number. vi. The McLean Bible Church MERT (Medical Emergency Response Team) will be called, if available. 4. Please remember to take your child s epinephrine injectors with you at the end of the class or event. Kid s Quest staff is not responsible for any medication left at MBC and does not store epinephrine injectors overnight. If you accidentally leave epinephrine injectors you will be called to come pick them up from Kid s Quest Volunteer Central (located by the Café). 2

3 DETAILED HEALTH FORM (Part 1 Health and Allergy Concerns) Child s Name: Birth Date: Age: Father s Name: Cell Phone: Mother s Name: Cell Phone: Legal Guardian s Name: Cell Phone: Doctor s Name: Office Phone: My child has diabetes My child has asthma My child has My child is allergic to: Food (peanuts, tree nuts, shellfish, etc.) Animals, or Insect stings or bites (dogs, cats, bee stings, fire ants bites, spider bites, etc.) Drug or Medication (Penicillin, etc.) Environmental Agents (dust, pollen, mold, animal dander, poison ivy or oak) Latex Other My child no longer has allergic reaction symptoms to: If your child has a severe allergy that requires the administration of an epinephrine injector, please complete the Epinephrine Injector Administration Permission Form on the reverse side of this form. I have read and understand that Kid s Quest will not administer any medication except for an epinephrine injector by a trained staff member or key volunteer in the event of an emergency. Parent or Legal Guardian Printed Name Parent or Legal Guardian Signature Date 3

4 DETAILED HEALTH FORM (Part 2 - Epinephrine Injector Administration Permission) To be completed by parent or legal guardian and kept on record by Kid s Quest staff: Child s Name (as it appears on the epinephrine injector): I hereby authorize the McLean Bible Church (MBC) Kid s Quest staff and volunteers to administer an epinephrine injector to my child if he or she has known exposure and/or a severe allergic reaction to a specified allergen. I agree to release, indemnify, and hold harmless MBC and any of its staff, volunteers, or agents from lawsuit, claim, expense, demand, or action against them for administering the epinephrine injector provided they administer the epinephrine injector prescribed specifically for my child. I am aware that the injection will probably be administered by a trained staff member or volunteer who is not a healthcare professional. I have read the Allergy Information and Epinephrine Injector Administration Policies and Procedures and agree to provide two epinephrine injectors as required. I understand that the 911 Rescue Squad will always be called when an epinephrine injector is administered to my child. The following epinephrine injector has been prescribed. Check as appropriate: EpiPen (the premeasured dose is 0.3mg. of Epinephrine) EpiPen Jr. (the premeasured dose is 0.15mg. of Epinephrine) Auvi-Q for patients over 66 lbs (the premeasured dose is 0.3mg. of Epinephrine) Auvi-Q for patients lbs (the premeasured dose is 0.15mg. of Epinephrine) My child has received adequate training on how and when to use an epinephrine injector and can use it properly in case of an emergency. He or she will carry an epinephrine injector at all times. Parent or Legal Guardian Printed Name Parent or Legal Guardian Signature Date To be completed by a Kid s Quest staff member/coordinator: The above has been reviewed with the parent or legal guardian. Additional remarks: Kid s Quest Staff Printed Name Kid s Quest Staff Signature Date 4

5 EPINEPHRINE INJECTOR ADMINISTRATION PERMISSION FORM To be completed by parent or legal guardian and placed in zip lock bag with epinephrine injector: Child s Name (as it appears on the epinephrine injector): Child s Age/Grade: Parent/Guardian Emergency Cell/Phone: My Child is Allergic To: I hereby authorize the McLean Bible Church (MBC) Kid s Quest staff and volunteers to administer an epinephrine injector to my child if he or she has known exposure and/or a severe allergic reaction to a specified allergen. I agree to release, indemnify, and hold harmless MBC and any of its staff, volunteers, or agents from lawsuit, claim, expense, demand, or action against them for administering the epinephrine injector provided they administer the epinephrine injector prescribed specifically for my child. I am aware that the injection will probably be administered by a trained staff member or volunteer who is not a healthcare professional. I have read the Allergy Information and Epinephrine Injector Administration Policies and Procedures and agree to provide epinephrine injectors as required. I understand that the 911 Rescue Squad will always be called when an epinephrine injector is administered to my child. The following epinephrine injector has been prescribed. Check as appropriate: EpiPen (the premeasured dose is 0.3mg. of Epinephrine) EpiPen Jr. (the premeasured dose is 0.15mg. of Epinephrine) Auvi-Q for patients over 66 lbs (the premeasured dose is 0.3mg. of Epinephrine) Auvi-Q for patients lbs (the premeasured dose is 0.15mg. of Epinephrine) My child has received adequate training on how & when to use an epinephrine injector and can use it properly in case of an emergency. He or she will carry an epinephrine injector at all times. Parent/Legal Guardian Printed Name Parent/Legal Guardian Signature Date EPINEPHRINE INJECTOR ADMINISTRATION PERMISSION FORM To be completed by parent or legal guardian and placed in zip lock bag with epinephrine injector: Child s Name (as it appears on the epinephrine injector): Child s Age/Grade: Parent/Guardian Emergency Cell/Phone: My Child is Allergic To: I hereby authorize the McLean Bible Church (MBC) Kid s Quest staff and volunteers to administer an epinephrine injector to my child if he or she has known exposure and/or a severe allergic reaction to a specified allergen. I agree to release, indemnify, and hold harmless MBC and any of its staff, volunteers, or agents from lawsuit, claim, expense, demand, or action against them for administering the epinephrine injector provided they administer the epinephrine injector prescribed specifically for my child. I am aware that the injection will probably be administered by a trained staff member or volunteer who is not a healthcare professional. I have read the Allergy Information and Epinephrine Injector Administration Policies and Procedures and agree to provide epinephrine injectors as required. I understand that the 911 Rescue Squad will always be called when an epinephrine injector is administered to my child. The following epinephrine injector has been prescribed. Check as appropriate: EpiPen (the premeasured dose is 0.3mg. of Epinephrine) EpiPen Jr. (the premeasured dose is 0.15mg. of Epinephrine) Auvi-Q for patients over 66 lbs (the premeasured dose is 0.3mg. of Epinephrine) Auvi-Q for patients lbs (the premeasured dose is 0.15mg. of Epinephrine) My child has received adequate training on how & when to use an epinephrine injector and can use it properly in case of an emergency. He or she will carry an epinephrine injector at all times. Parent/Legal Guardian Printed Name Parent/Legal Guardian Signature Date 5

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