Anaphylaxis (Life Threatening Allergy) Information Emergency Plan For(Required)Facility Name(Required)Facility Address(Required)Child's Full Name(Required)Date Of Birth(Required) MM slash DD slash YYYY Photo(Required)Max. file size: 512 MB.Parent/Guardian Name(Required)Home Phone(Required)Work Phone(Required)Emergency Contact(Required)Home Work(Required)Work Phone(Required)Primary Care Provider(Required)Work Phone(Required)Child's Anaphylaxis Triggers AreTriggers(Required) Peanuts Nuts Milk All Dairy Eggs Shellfish FishFood AdditivesInsect StingsMedicationsOtherChild's Anaphylaxis Symptoms Are Usually Swelling (eyes, lips, face, tongue) hives or itchy skin cold, clammy, sweaty skin fainting or loss of consciousness stomach cramps/diarrhea/vomiting difficulty breathing/swallowing tingling of lips/mouth coughing or choking flushed face or body dizziness , confusion change of voice heart rate changes othersChild's Emergency TreatmentMedication Is Stored WhereEpinephrine Auto-Injector - Expiry Date MM slash DD slash YYYY Name Of Staff Oriented To PlanEmergency Plan Review Date (To Do Early) MM slash DD slash YYYY Field Trips PlansIt is parents responsibility to notify the facility of any change in the child's conditionSign below or write your name if you agree with above information & planPrimary Care ProviderDate MM slash DD slash YYYY Parent/GuardianDate MM slash DD slash YYYY Childcare Supeisor/School PersonnelDate MM slash DD slash YYYY
