Allergy Care Plan

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Allergy Care Plan Name of Child______________________________________

Date_________________

Name of Emergency Contact________________ Name of Emergency Contact_______________ Telephone Numbers: Telephone Numbers: Home_________________________ Home_________________________ Cell___________________________ Cell___________________________ Work__________________________ Work__________________________ Name of Physician___________________________________Phone_______________________ Name and Location of Clinic___________________________ Please list any exposure that your child could come onto contact with on our premises by listing specific items containing allergens that could be ingested, inhaled, and/or as a result of topical exposure. For example, if your child is topically allergic to wheat and cannot touch play dough, please list play dough for exposure. If the employee directed staff response includes any medication, (ex. Benadryl), parent must provide the medication. If your child has no allergies, write, “No known allergies.” Please note that this Allergy Care Plan is not confidential information and will be posted for staff to see. Allergen

Manner of Exposure

Possible Reactions

Employee directed Staff Response

By completing and signing this form the signature acknowledges that while every effort will be made to limit exposure to known allergens; accidental exposure may be unavoidable. In the event your child is experiencing a reaction that is gaining medically necessary momentum, all “Employee Directed Staff Responses” may be bypassed and staff may call 911. Parent/Guardian Signature__________________________________________ Date__________________________________