2965 Hwy 43, Kemptville +1-613 258-1931

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

Please read and fill out the form below

Student Information


Epinephrine auto-injector expiry date:


ADDITIONAL NOTES (if applicable):

PARENTAL STATEMENT

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.


EMERGENCY CONTACT INFORMATION


HEALTHCARE PROFESSIONAL CONTACT INFORMATION: (optional)


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.