Individualized Plan and Emergency Procedures for a Child with an Anaphylactic Allergy

Please read and fill out the form below

Student Information

Last Name

First Name

Date of Birth

List of Allergen(s)/Causative Agent(s)

Photo of Child (recommended)

Asthma

Yes (higher risk of severe reaction) No

Location of medication storage:

Epinephrine auto-injector brand name:

Epinephrine auto-injector expiry date:

Other emergency medications*:

Emergency Services Contact Number:

CHILD’S SPECIFIC SIGNS AND SYMPTOMS OF A NON-LIFE THREATENING ANAPHYLACTIC REACTION: (specific to the child, e.g. wheezing and itchy skin)

CHILD’S SPECIFIC SIGNS AND SYMPTOMS OF A LIFE THREATENING ANAPHYLACTIC REACTION: (specific to the child, e.g. inability to breathe, sweating)

DESCRIPTION OF PROCEDURE TO FOLLOW IF CHILD HAS A NON-LIFE THREATENING ANAPHYLACTIC REACTION:

DESCRIPTION OF PROCEDURE TO FOLLOW IF CHILD HAS A LIFE-THREATENING ANAPHYLACTIC REACTION:

STEPS TO REDUCE RISK OF EXPOSURE TO CAUSATIVE AGENT/ALLERGEN: (e.g. nut-free environment)

ADDITIONAL NOTES (if applicable):

PARENTAL STATEMENT

I hereby give consent for my child to (check all that apply):

carry their emergency allergy medication in the following location

self-administer their own medication in the event of an anaphylactic reaction

Child's Name

Parent Name Sign Off

AND / OR

I hereby give consent to any person with training on this plan at the home child care premises to administer my child’s epinephrine auto-injector and/or asthma medication and to follow the procedures set out in my child’s Individualized Anaphylaxis Plan and Emergency Procedures.

Parent/Guardian Initials

EMERGENCY CONTACT INFORMATION

Emergency Contact Name 1

Relationship to Child

Primary Phone Number

Additional Phone Number

Emergency Contact Name 2

Relationship to Child

Primary Phone Number

Additional Phone Number

HEALTHCARE PROFESSIONAL CONTACT INFORMATION: (optional)

Healthcare Professional Contact Name

Healthcare Primary Phone Number

Signature / Sign-off Healthcare Professional (optional)

Date

Signature of Parent / Guardian

Date

SPECIAL INSTRUCTIONS

*Written parental authorization for the administration of drugs and medications must be completed and implemented for medications other than epinephrine auto-injectors.

• Each child with an anaphylactic allergy requires their own individualized plan. If significant changes and updates are required to this individualized plan, a new individualized plan must be completed.

• Children’s personal health information should be kept confidential.