EMERGENCY CONTACTS

Oregon Department ofAllergy Care Plan Early Learning and Care
Date received by child care

MonthDayYear
Date
CHILD INFORMATION
Childs Full Name
Group/Classroom
EMERGENCY CONTACTS
*The parent must be notified immediately of any suspected allergic reactions, or if the child came in contact with the allergen even if a reaction did not occur. NamePhone # Relationship
Name
Relationship
Phone
Format: (000) 000-0000.
Name
Relationship
Phone
Format: (000) 000-0000.
Name
Relationship
Phone
Format: (000) 000-0000.
CHILD'S ALLERGY INFORMATION
Format: (000) 000-0000.
My child has a severe allergry to:
Describe signs and symptoms of an allergic reaction including asthma if applicable
How to avoid the allergen and prevent an emergency
EMERGENCY RESPONSE PLAN List the steps and procedures to follow during an emergency related to your childs allergy
MEDICATIONS* Medication Authorization Form must be completed for each medication. Describe symptoms that would prompt emergency medication to begiven.
List medication to be given during an emergency:
Dosage
Directions
Expiration Date

MonthDayYear
Date
*If epinephrine is administered, emergency medical services must be contacted immediately, and CCLD by 5pm the next business day.
SIGNATURES
Parent or Guardian Signature
Date

MonthDayYear
Date
Health Care Provider Signature recommended
Date

MonthDayYear
Date
Oregon Department of Early Learning and Care Child Care Licensing Division www.oregon.gov/delc I PR-0482 (12/2023)
List medication to be given during an emergency: Name of Medication Dosage
Should be Empty:

CHILD INFORMATION

EMERGENCY CONTACTS

SIGNATURES