Anaphylaxis Emergency Plan

Anaphylaxis Emergency Plan
Camper Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sessions Registered For*

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

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

Yes (high risk to for server reaction)NoOther
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 NameLast Name
Phone Number 1*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: