Anaphylaxis Emergency Plan

Anaphylaxis Emergency Plan
Camper Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Sessions Registered For *

Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8 Session 9

Must Be Completed for Campers Bringing Medication to Camp
Allergy to *
Asthma? *

Yes (high risk to for server reaction) No Other
Has Camper had a previous anaphylactic response? If yes, when? *
What symptoms did they show? *
Has Participant ever self-administered an epi-pen? If yes, when? *
Doseage *

EpiPenJr. (0.15 mg) EpiPenJr. (0.30 mg) Twinject (0.15 mg) Twinject (0.30 mg) Other
Other medication/dose/route
Is there anything else we should know?

Parent/Guardian Information
Name *

First Name Last Name
Phone Number 1 *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: