ANAPHYLACTIC ALLERGY FORM

INDIVIDUALIZED PLAN AND EMERGENCY PROCEDURES FOR A CHILD WITH AN ANAPHYLACTIC ALLERGY
Special Instructions:
- 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.
Child's Name*

First NameLast Name
Child Photo

Photo of Child
Cancelof
Child's Date of Birth *

MonthDayYear
Date
List of allergen(s) / causative agent(s):*
Asthma:

Yes (higher risk of severe reaction)No
Location of medication storage:
Epinephrine auto-injector brand name:
Epinephrine auto-injector expiry date:

MonthDayYear
Date
Other emergency medications:
Written parental authorization for the administration of drugs and medications must be completed and implemented for medications other than epinephrine auto-injectors.
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)
DESCRIPTION OF PROCEDURE TO FOLLOW IF CHILD HAS A NON-LIFE THREATENING ANAPHYLACTIC REACTION:
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 LIFE-THREATENING ANAPHYLACTIC REACTION:
STEPS TO REDUCE RISK OF EXPOSURE TO CAUSATIVE AGENT/ALLERGEN (e.g. nut free environment):
ADDITIONAL NOTES (if applicable): (e.g. use of other emergency allergy medication(s) to implement the emergency procedures)
Parent Statement:

I give consent to any person with training on this plan at the 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
Relationship to child
Primary Contact Number
Additional Contact Number
HEALTHCARE PROFESSIONAL CONTACT INFORMATION
Healthcare Contact Name
Healthcare Contact Number
SIGNATURE OF PARENT/GUARDIAN (required)
Print name
Relationship to Child
Signature

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Date

MonthDayYear
Date
Parent's Email
example@example.com
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INDIVIDUALIZED PLAN AND EMERGENCY PROCEDURES FOR A CHILD WITH AN ANAPHYLACTIC ALLERGY

EMERGENCY CONTACT INFORMATION

HEALTHCARE PROFESSIONAL CONTACT INFORMATION