SEVERE Allergy Information
Name _____________________________
Grade____ Teacher_______________________
Bus#_______
Prime Time ___am___ pm
Car Rider ___am___ pm
Parent/Guardian Name______________________ phone _____________phone_____________
Name__________________________ phone_____________ phone_____________
Emergency contact ________________________________
phone__________________________
Relationship
Allergy:
____Food
____Bees
____ Fire ants
____ latex
____unknown
Type of allergic reaction: ____Eat (ingestion) ____Touch (contact) ____ Smell(inhalation)
Known Food allergies: please list____________________________________________
___________________________________________________
Has your child had a severe allergic reaction requiring immediate medical attention?
______yes
_______no
If yes, when?___________________________
Symptoms (please circle symptoms your child displays)
Redness/Itching around mouth
Swelling of lips, tongue, face
Hoarseness/cough
Diarrhea/Nausea/Vomiting
Hives
Red itchy blotches
Flushed Skin
Feeling of itching inside
Shortness of Breath
Swelling of the Throat
Painful constriction of the chest
Restlessness
Wheezing
Fear
Rapid Pulse
Unconsciousness
Local swelling/redness at site of sting/bite only
Local skin contact only(Latex)
Medication required: _____yes ____no
If yes, name of medication(s) _____________________________________________
A doctor’s Authorization Form is required for any medication at school.
A Severe Allergy Emergency Plan is attached for the doctor to complete and sign. A parent
signature is also required
.
I authorize the release and exchange of medical and educational information between my child’s physician
and school staff necessary in carrying out this service to my child.
PARENT/GUARDIAN SIGNATURE_________________________________________ DATE___________
SCHOOL NURSE SIGNATURE_____________________________________________ DATE___________
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