EMERGENCY ANAPHYLACTIC ALLERGY PROCEDURES Child’s Name* Child's Date of Birth* DD dash MM dash YYYY List of allergen(s)/causative agent(s)*Asthma* Yes No (higher risk of severe reaction)Photo of The Child (Recommended)Accepted file types: jpg, png, Max. file size: 2 MB.Location of medication storage* Epinephrine auto-injector brand name* Epinephrine auto-injector expiry date* DD dash MM dash YYYY Other emergency medications* Emergency Services Contact Number* CHILD’S SPECIFIC SIGNS AND SYMPTOMS OF A NON-LIFE-THREATENING ANAPHYLACTIC REACTION*(specific to the child, e.g. wheezing and itchy skin)CHILD’S SPECIFIC SIGNS AND SYMPTOMS OF A LIFE-THREATENING ANAPHYLACTIC REACTION*(specific to the child, e.g. inability to breathe, sweating)DESCRIPTION OF PROCEDURE TO FOLLOW IF CHILD HAS A NON-LIFE-THREATENING ANAPHYLACTIC REACTION*PS TO REDUCE RISK OF EXPOSURE TO CAUSATIVE AGENT/ALLERGEN*(e.g. nut-free environment)ADDITIONAL NOTES (if applicable)*(e.g. use of other emergency allergy medication(s) to implement the emergency procedures)Parental StatementI hereby give consent for my childParent/Guardian* Child’s name* Parental Statement* carry their emergency allergy medication in the following location self-administer their own medication in the event of an anaphylactic reaction AND/ORI (parent/guardian) hereby give consent to any person with training on this plan at the home child care premises to administer my child’s epinephrine auto-injector and/or asthma medication and to follow the procedures set out in my child’s Individualized Anaphylaxis Plan and Emergency Procedures.Parent/Guardian initials* EMERGENCY CONTACT INFORMATIONContact Name* Relationship to Child* Primary Phone Number*Additional Phone Number*HEALTHCARE PROFESSIONAL CONTACT INFORMATION: (optional)Contact Name* Primary Contact Number*Consent* By checking this box you are agreeing the terms and conditions mentioned on the form and also confirming that the information above is accurate.*CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
