Seizure Emergency Action Plan ForDate MM slash DD slash YYYY Child's Name(Required) First Last Age(Required)Centre Name:(Required)Centre Address(Required)Child 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 Name(Required)Home Phone(Required)Work Phone(Required)Health Care Provider Name(Required)Phone(Required)HistoryType Of Seizure:(Required)Date Of Last Seizure(Required) MM slash DD slash YYYY How Often Do They Occur(Required)Student Wears A Medic-Alert(Required) Yes NoIs The Student Taking Medication(Required) Yes NoIf Yes Name Of Medication(Required)Dose(Required)How Long Have They Been Taking This Medication(Required)Additional Information About Medication(Required)Usual Seizure PresentationWhat Happens During A Seizure(Required)Warning Signs Before A Seizure(Required)Care Plan InformationName Of Staff Oriented To The Plan(Required)Emergency Plan Review Date(to be reviewed yearly)(Required) MM slash DD slash YYYY it is the parent's responsibility to notify the facility of any change in the child's conditionSign below or write names if you agree with above information & plansParent/GuardianDate(Required) MM slash DD slash YYYY Child Care Staff(Required)Date(Required) MM slash DD slash YYYY
