Food Allergy Information/Other Severe Reactions
Student _______________________________________________DOB________________Grade_____________
Parent_____________________________________________phone_______________cell_____________work_____________
My child has no food/other allergies. Signed________________________________date_________You are finished with this form.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------My child has severe food/other allergies _____________ (Fill out the rest of this form)
Please disclose whether your child has a food allergy or other severe allergy such as bee sting. The District will use this information
to take the necessary precautions for your child’s safety.
Food/ other allergy
Physical Reaction
Life threatening?
Needs Benadryl?
Has a EpiPen?
(Anaphylaxis)Signs and Symptoms of Severe Food/Other Allergy Symptoms
Mouth: Tingling, itching, swelling of the tongue, lips or mouth; blue/grey lips Throat: Tightening of throat; tickling feeling, change in voice
Nose/Eyes/Ears: Runny, itchy nose; redness/ swelling of eyes; throbbing in ears Lung: Shortness of breath; cough; wheezing
Stomach: Nausea; vomiting; diarrhea; abdominal cramps Skin: Itchy rash; hives; swelling of face or extremities; facial flushing
Heart: Thin weak pulse; rapid pulse; palpitations; fainting; blueness of lips, face or nail beds; paleness
911 will be called with any signs of anaphylactic symptoms.
If you are reporting a severe allergy, you need to discuss this matter with your child’s physician to see what the best plan of action
for your child should be. A Parent/Physician form is required for all EpiPens.
___I will bring/send my child’s nonprescription antihistamine medication to administer in the case
of an allergic reaction. I will fill out the medication request and sign upon medication delivery to school.
___I will send an EpiPen. (Follow up paper work will be sent out for the Physician to fill out and sign.)
___I do not wish to keep medication at school for my child in case of an allergic reaction. I will
not hold Jacksboro ISD responsible for any adverse event that occurs to my child because of not
having provided the appropriate medication for this allergy.
If you send medication to school:
1. A medication request form is required for all nonprescription medication and must be signed by a parent/guardian. The
medication must be current and in the original container.
2. EpiPens must have a current prescription label and remain in the original container. The Emergency Allergy Care Plan form must
be filled out, signed by you and your child’s physician, and returned to the School Nurse.
The District will maintain the confidentiality of the information provided and disclose to Jacksboro personnel within the limitations
of the Family Educational Rights and Privacy Act and District Policy.
________I give a representative of Jacksboro ISD permission to release my child’s allergy information via fax to their listed Physician
and request that Physician fill out and return the Emergency Allergy Care Plan form for Epi Pen use to Jacksboro ISD. Otherwise,
the parent is responsible for getting Physician signature.
Physician____________________________________________________phone__________________fax___________________
Parent signature______________________________________________________date__________________