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: 2 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 Fish Food Additives Insect Stings Medications Other Child'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 others Child's Emergency TreatmentMedication Is Stored Where Epinephrine Auto-Injector - Expiry Date MM slash DD slash YYYY Name Of Staff Oriented To Plan Emergency Plan Review Date (To Do Early) MM slash DD slash YYYY Field Trips Plans It is parents responsibility to notify the facility of any change in the child's condition Sign below or write your name if you agree with above information & planPrimary Care Provider Date MM slash DD slash YYYY Parent/Guardian Date MM slash DD slash YYYY Childcare Supeisor/School Personnel Date MM slash DD slash YYYY
