Emergency Health Care Plan Form (Page 2 of 2) in pdf

SEVERE ALLERGY INFORMATION

Child’s Name____________________________________________________

DOB _____________________

Child Care Program ______________________________ Child Care Provider ____________________________

Allergies: (food, insects, medication, etc)

Reaction: (include date of last reaction)

Diet Restrictions: (For food allergies, parents will monitor child care program menus or

provide special food for their child.)

Medications used on a daily basis: (include doses)

1. ___________________________________ 2. _________________________________

3. ___________________________________ 4. _________________________________

REMINDER  Child care staff must take EpiPen® or any other medication on field trips

 Child care staff should take a phone with them on field trips

 Keep EpiPen® at room temperature, DO NOT freeze, refrigerate, or keep in extreme heat

EMERGENCY CONTACT INFORMATION

Father’s/Guardian’s name:

Mother’s/Guardian’s name:

Address: _______________________________

Address: ______________________________

Home Phone: ____________ Work Phone: __________

Home Phone: _________ Work Phone: _________

Alternate contact person if parent cannot be reached:

Name: ___________________ Relationship:

Name: ________________________________

Address: _______________________________

Address: ______________________________

Home Phone: ____________ Work Phone: __________

Home Phone: ________ Work Phone: __________

Physician who should be called regarding the allergic reaction:

Name: __________________________________

Address: ________________________________ Phone: ___________________

Hospital Preference: _______________________________________________________________________

It is understood by the parent(s) and health care provider that this plan may be carried out by child care personnel per

the information provided above.

Prescribing Practitioner Signature _________________________________________

Date ________________

Parent/Guardian Signature _______________________________________________

Date ________________

Child Care Director/Provider Signature ______________________________________

Date ________________

10/06

EMERGENCY HEALTH CARE PLAN

SEVERE ALLERGY

Emergency Health Care Plan Form Page 2