Parent/Guardian Business Information

Eye Color: Identified Allergies: Identifying Marks: Health Insurance Provider:

Name of Physician/Clinic: Physician Address:

Reg. Fee Rec'd: Yes No Director's Initials:

Suspected Allergy/Food and Tolerance Form

This form is to be completed by the parent/guardian when the parent/guardian suspects their child may be allergic to a product or has a food intolerance; however, has not received a medical diagnosis or a health care plan from the child's medical provider.

Note: If the suspected allergy or food intolerance is medically diagnosed, a Health Care Plan completed and signed by the child's medical provider is required (provided by the center

I suspect/am concerned my child may be allergic for the following reasons: Family History No previous exposure Previous Reaction (please explain/date or reaction):

I understand that Lovin' Touch Learning Center requires the most up to date information regarding my child's suspected allergy/food intolerance. I also understand that for the safety of my child, my child's photograph and allergy information will be posted in the classrooms and kitchen.

This form must be updated annually or whenever there is any change in treatment or the child's condition changes.

To eliminate the suspected allergy or food intolerance and allow your child to eat the suspected item(s) while at LTLC, please complete the following. acknowledge that my child no longer has a suspected allergy to and may now be served this item(s) while at LTLC.

The following information should be completed by the child's health care provider.

Specific Medical Information: Medication to be administered:*

YesNoIf yes, medication to be administered and potential side

*For complete medication administration information, it may be necessary for the medical provider and parent/guardian to complete the Medication Authorization form.

Potential Consequences to child if treatment is not administered:

Additional Emergency Procedures/Instructions (including when 911 should be called):

Is breathing regularly Has no coughing or wheezing Can engage in active play

"As needed medication" not needed Regular medication to be given as ordered.

Early signs of a cold (runny nose. sneezing) Exposure to a known trigger Coughing Mild wheezing Chest tightness

Cease current activity If the child is outdoors, bring inside Observe breathing before and after the treatment (15 minutes)

Administer the "as needed medication" per the Medication Authorization Form and follow directions for use Monitor breathing status. If no improvement, follow the steps for DANGER (Red Zone)

If the child's asthma is worse and any of the following apply: The medications are not helping within 15-20 minutes of administration Breathing is becoming hard and fast Nose (nostrils) open wide Ribs are showing Lips, fingernails or mouth area are blue or blue gray in color Trouble walking or talking

Call 911 Stay with the child - stay calm Ancillary staff notify the parent/guardian Complete an Occurrence Report within 24 hours

Medication available has already been given with no relief Notify EMS staff regarding the type of medication and the time it was given.

Parent/Guardian Acknowledgement Statement To ensure the safety of your child we cannot delete a health care diagnosis which has previously been documented unless we have a signed note from the child's physician stating that the condition no longer exists; nor can we add an item(s) or change a medication without a signed note from the child's physician. I understand that LTLC requires the most up to date information regarding my child's health. I also understand that for the safety of my child, my child's photograph and health information will be posted in the classrooms and kitchen.

This plan must be updated annually or whenever there is any change in treatment or the child's condition changes.

Type of allergy transmission/trigger:

Note: Do not depend on Antihistamines or inhalers to treat a SEVERE reaction. USE

Extremely reactive to the following foods therefore: If checked, give epinephrine for ANY symptoms if the allergen was likely eaten. If checked, give epinephrine immediately if the allergen was definitely eaten, even if no symptoms are noted.

For the following signs of a mild allergic reaction administer:

Skin: Hives: Mild Itch Stomach: Mild Nausea/Discomfort Other:

Nose: Itchy, Runny, Sneezing Mouth: Itchy

For any of the following signs of a SEVERE allergic reaction or a combination of symptoms from different body areas, give EPINEPHRINE and call 911. If prescribed and directed. Give other medications (antihistamine/inhaler Lay person flat. If breathing is difficult or vomiting, place on side, or sit up.

Mouth: Significant swelling of tongue and/or lips pulse, dizzy

Throat: Tight, hoarse, trouble breathing/swallowing Skin: Many hives over body, widespread redness, severe diarrhea vomiting. severe diarrhea Other: Feeling something bad is about to happen; anxiety, confusion Other Medication Instructions:

Lungs: Short of breath Stomach: Repetitive

Prescribed Medications/Dosage Epinephrine (brand and dose): Antihistamine (brand and dose): Other (i.e., inhaler-bronchodilator if asthmatic): Potential Side Effects of Medication:

Parent/Guardian Acknowledgement Statement To ensure the safety of your child we cannot delete an allergy which has previously been documented unless we have a signed note from the child's physician stating that the child is no longer allergic to that item(s) and may now have that specific food(s); or be exposed to the item(s); nor can we add an item(s) or change a medication without a signed note from the child's physician. I understand that LTLC requires the most up to date information regarding my child's allergy. I also understand that for the safety of my child, my child's photograph and allergy information will be posted in the classrooms and kitchen.

This plan must be updated annually or whenever there is a change in treatment or the child's condition changes.

For complete medication administration information, it may be necessary for the medical provider and parent/guardian to complete the Medication Authorization form.

Sunscreen and Insect Repellent - Permission

Sunscreen and insect repellent should be applied to a child at least once at home to test for any allergic reaction. Aerosols, sprays and combined sunscreen/insect repellents are prohibited.

Sunscreen must provide UVB and UVA protection with an SPF of 15 or higher. Sunscreen may not be used on infants under 6 months of age, unless parent permission below is granted.

Insect repellent may only be used if recommended by public health authorities or requested by a parent/guardian. The repellent must contain a concentration of 30% DEET or less. Insect repellent may not be used on infants under 2 months of age. Oil of lemon eucalyptus and paramethane products may not be used on children under the age of three.

All sunscreen and insect repellent provided by a parent/guardian must be: Provided in the original container; Clearly labeled with the child's full name; Within the expiration date; Appropriate for the age of the child; and Free of nut ingredients.

Complete one of the following: I give LTLC permission to apply (name of sunscreen) and/or (name of insect repellent) When outdoor conditions warrant and consistent with package instructions (subject to any special from instructions below) to my child, (not to exceed one year insect repellent to my child I do not give LTLC permission to applyIsunscreen and/or I do not hold LTLC responsible for my decision and understand that my child may be sunburned/bitten as a result. I understand that I should provide protective clothing including a hat, lightweight long sleeve shirt and pants instead, to protect my child from sun exposure and insects during outdoor activities.

Cultural/Religious/Vegan/Vegetarian Reasons

This form is required for any child who should not be served particular foods due to cultural/religious/vegan or vegetarian reasons, but excluding medical causes (i.e. allergies) or personal preferences (i.e. dislike of certain foods

Where possible, LTLC offers vegetarian options or food substitutions. As permitted by licensing, families may bring their own food from home, so long as it is "nut safe". Milk alternatives that are "nut safe" are permitted, but will be provided by the family if not offered at the location.

In order to manage any permitted food preferences, a child's photograph with the limitations must be posted in the classrooms and kitchen on a Food Preference Chart for staff to follow. I understand that LTLC cannot guarantee that my child will not be exposed to a particular food, and that any changes to the preferences stated below must be made by me in writing.

Due to cultural/religious/vegan or vegetarian reasons, I request that my child is not served the following foods:

To eliminate a food preference(s) and to permit a food to be served to your child, please complete the following. . acknowledge that my child is now able to eat

and may be served this item(s) at LTLC.