.31S !-Iillside :\venue
Demarest, New Jersey 07627
201 768-7822 ext. 218
201 768-0530 FAX
bcalthoffice@holyattgels.org
ACADEMY
C'f 1f:r
wurw.holyangels.org
HOLY ANGELS
r. •,!::.;nl n
::-tr:
EMERGENCY HEALTH CARE PLAN
ALLERGYTO:
Students
---Student ID Picture:
Name: ---------------D.O.B: --- -- HR:
- --Asthmatic: Yes
*
No
*High Risk for Severe Reaction
--
SIGNS OF AN ALLERGIC REACTION:
Systems:
Symptoms:
Mouth
itching & swelling of lips, tongue, or mouth
Throat*
itching and/or a sense of tightness in throat, hoarseness, hacking cough
Skin
hives, itchy rash, and/or swelling of face, extremities
Gu(
nausea, abdominal cramps, vomiting, and/or diarrhea
Lung*
short of breath, repetitive cough, wheeze
Heart*
"thready" pulse, passing out
The severity of symptoms can quickly change. *All above symptoms can potentially progress to a life-threatening
situation!
ACTION:
1. If ingestion is suspected, give -- -- - - -:::-:- -.---:-:----:---,--- --- - - - -(Medi caLion/dose/route)
and
_
_
__
_
_
immediately!
2. Call911 if: --- ---- - - - - - - - - - -- - ----- - - 3. Call Mother
_-=--=---=-- __--=-=---=----or emergency contacts.
-'Father
(Number)
(Number)
4. Call Dr:
at (phone)
_
_
EMERGENCY MEDICATION WILL BE ADMINISTERED AND 911 ACTIVATED EVEN IF PARENTS AND
PHYSICIAN CANNOT BE REACHED.
--------------- -------- ---------------MD
Parent Signature
Date
EMERGENCY CONTACTS
l.
Physician Signature
___ 1.
Date
TRAINED STAFF MEMBERS
_
_
Relation ------------Phone
2.
Relation ------------
-
. - - -- ··Plicfne
Ext
___ 2.
_
- -· ----·-- --·-Ext----------- -------· ····- - - -· ----------------------- -
_ 3.
3. _
Relation -- --
---
-Phone
SPONSORED by THE SCHOOL SfSTERS ofNOTRE DAME
Ext