Allergy & Dietary Care Plan

Child's Name

Please select one

My child has no known allergies, sensitivities, or dietary restrictions.

My child has one or more allergies, sensitivities, or dietary restrictions. I will complete the information below.

If none, please continue to signature field at bottom of page.

Parent/Guardian Name

Phone

The parent/guardian 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.

Emergency Contact

Relationship

Phone

Allergy Information

My child has an allergy 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 child's allergy

Medications

Describe symptoms that would prompt emergency medication to be given

Medications

Antihistamine

Inhaler

Epi-pen

Other

Medication Authorization Form must be completed for each medication

Name of Medication

Dosage

Directions

Expiration Date

If epinephrine is administered, emergency medical services must be contacted immediately, and CCLD by 5pm the next business day.

Dietary Retrictions & Sensitivities

Please list any dietary restrictions, food sensitivities, cultural or religious dietary practices, or foods your child should avoid

If a substitute snack is needed due to your child's dietary needs, what foods are acceptable?

Signature

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Date