Add your student’s
picture here.
GSLC Allergy Management Plan
2012-2013 Sunday School Year
Name of Student:
Age:
Is the student asthmatic?
Date of Birth:
Grade:
Yes*
No
*Higher risk for reaction
Please list all Allergies:
Symptoms of an allergic reaction in my student may include (please add more symptom detail
specific to your student at the end of each symptom):
Mouth – itching and swelling of the lips, tongue or mouth.
Throat – itching and/or a sense of tightness in the throat, hoarseness, and a
hacking cough.
Skin – hives, itchy rash, and or swelling about the face or extremities, flushing
or paleness of the skin.
Gut – nausea, abdominal cramps vomiting, and/or diarrhea.
Lung – shortness of breath, repetitive cough, wheezing.
Heart – rapid pulse, drop in blood pressure, unconsciousness.
Sunday School Management Plan: Avoidance Strategies
(Please list all instructions that Sunday School volunteers should know about how to prevent exposure to your child’s allergen.
Consider sources contained in food, craft materials and environment.)
*Does this student have an antihistamine?
Yes
Location of antihistamine during Sunday School?
On-Child
Teacher
Parent
*Does this student have an Epipen?
Yes
Location of Epipen during Sunday School?
On-child
Teacher
Parent
No
No
*Please complete the Medication Administration and Emergency Notification sections on
Page 2 of this document.
To be completed by Sunday School Staff:
Reviewed by: ________________
Copy placed in Rm Binder: Y N
Date: _______________________
Student listed on Allergy List: Y N
ALLERGY TREATMENT PLAN
In the event of exposure to an allergen, the following steps should be taken:
MEDICATION ADMINISTRATION
1) If a student has been exposed to an allergen, but shows no symptoms, administer:
No Medication
Epipen*
Antihistamine*
Other Medication*
*If this box is checked, please complete the following information:
Name of Medication:
Dosage:
**If Epipen is administered, call 9-1-1 IMMEDIATELY.
2) If a student has been exposed to an allergen and is showing the signs of an allergic
reaction, administer:
No Medication
Epipen*
Antihistamine*
Other Medication*
*If this box is checked, please complete the following information:
Name of Medication:
Dosage:
**If Epipen is administered, call 9-1-1- IMMEDIATELY.
EMERGENCY NOTIFICATION:
In the event of allergic exposure, parents/guardians will be contacted by Sunday School
volunteer/staff.
Parent/Guardian Name:
Parent/Guardian Emergency Number(s):
Emergency Contact:
Emergency Contact Number:
Relationship:
Student’s Doctor:
Doctor’s Phone Number:
Parent/Guardian Signature:
Date:
To be completed by Sunday School Staff:
Reviewed by: ________________
Copy placed in Rm Binder: Y N
Date: _______________________
Student listed on Allergy List: Y N