29818 S. North Pine Creek Road LIBERTY SCHOOL DISTRICT
Spangle, WA 99031
Phone: (509) 624-4415
Fax: (509) 245-3530
Orders/care plan valid from August 1, ______ through July 31, ___________.
Grade:
Allergies:
Teacher:
Other Health Concerns:
Date of Last Reaction: Routine Medications:
This Section To Be Completed By A Licensed Healthcare Provider (LHP):
Bus #:
If a student is showing allergy symptoms or you know or suspect they have eaten: ______________
1.

Give Epi auto-injector 0.3 mg Jr. 0.15 mg Student’s Weight: _______________ Date: _________
May repeat Epi auto-injector (if available) in 10-15 minutes if symptoms are not relieved, return or worsen and EMS has not arrived.
Document time medications were given below and alert EMS when they arrive.
_____________________ ______________________
Epi-pen #1 Epi-pen #2
_____________________
Antihistamine
_____________________
Inhaler
2.
An adult trained in CPR must stay with student until EMS arrives.
3. CALL 911 – Advise EMS that student has been given Epinephrine for an allergy to: _______________________
4. Notify school nurse (extension 2211) and parents.
5. After Epi auto-injection given:
Give antihistamine: ______________________ Dose: __________ mg. by mouth Frequency: ______________
6. If student has history of Asthma and is having wheezing, shortness of breath, chest/throat tightness with an allergic
reaction,
After Epi auto-injection and antihistamine, may give:
Albuterol 2 puffs (Pro-air®, Ventolin HFA®, Proventil®)
Levalbuterol 2 puffs (Xopenex®)
Albuterol/ Levalbuterol unit dose SVN (per nebulizer)
Other____________
7.
A Student given an Epi auto-injector may not remain at school and must be transported by EMS to the emergency room.
SIDE EFFECTS of medication(s):
Epi auto-injector: increased heart rate, Antihistamine: sleepiness
Albuterol/Levalbuterol: increased heart rate, shakiness,
 Yes  No Student may carry & self administer Epi auto-injector, rescue inhaler and/or antihistamine.
 Yes  No Student has demonstrated Epi auto-injector and/or rescue inhaler use in LHP’s office

PLEASE COMPLETE THIS SECTION IF THE STUDENT HAS A SEVERE FOOD ALLERGY (required by USDA)
Check here if student will EAT school provided meals during the entire school year. If so, one of the following must be completed.
1.
Foods to omit: ___________________________ Suggested general substitutions: ____________________________
2.
Check here if standard substitutions offered in our district are acceptable.
(Contact district Food Services Manager, 509-245-3211, ext. 2219, for details.)
Note: Meals from home provide the safest food option at school.
My signature below indicates that I have reviewed and approved the attached emergency care plan.
LHP Signature:
Start date: End date
(not to exceed current school year):
Date: Telephone #:
Print Name:
Last day of school Other:
Fax #:

Students with life-threatening allergies AND asthma have an increased risk of death with an allergic reaction.
Grade: Teacher:
Emergency medications are located in:  ________ Medication Cupboard  The student’s backpack.
 The student’s locker. Locker #: ________________ Combination: __________________
 The student’s bus#: _________  The student’s athletic coaches kit: _____________
Medications expire: Epi-Pen ___________ Benadryl: ______________ Inhaler: ________________
Anaphylaxis is a life-threatening allergic reaction to _________________ which may result in death in less than 15 minutes.
IF YOU SEE THIS:
________’s normal symptoms are in bold type.
Mental: “Feels scared or like “something bad is going to
happen”. Denial of symptoms. Changes in alertness.
Skin: Hives, itchy rash or flushing. Itchy, teary or
puffy eyes. Nasal congestion, runny nose or sneezing.
Mouth: . Itching, tingling, or swelling of the lips, mouth,
tongue or throat.
***Throat: Itching and/or a sense of tightness in the
throat, hoarseness, hacking cough.
***Gut: Nausea, cramps, vomiting and/or diarrhea.
***LUNGS: Rapid breathing > 30 breaths/minute.
Shortness of breath, repetitive coughing, or the
student is hunched over and struggling to breathe.
Chest tightness, hoarseness or choking.
***HEART: Increased heart rate > 120 beats/minute.
Thready, faint or irregular pulse. Blue lips or
nailbeds. Increased
restlessness. Pale, cool or moist skin. Dizziness
or fainting. Loss of consciousness.
BREATHING OR HEARTBEAT STOPS.
DO THIS:
- IF YOU KNOW OR SUSPECT ______________ HAS EATEN
OR COME INTO CONTACT WITH ____ ALLERGEN
SEND ____ TO THE OFFICE IMMEDIATELY OR CALL THE
OFFICE FOR HELP. NEVER SEND __________________
ANYWHERE ALONE!!!
- Notify the school nurse immediately at extension 2211.
- Give emergency medications as listed below.
1.)
2.)
- As soon as the Epi-Pen is given - CALL 911.
- An adult trained in CPR is to stay with ______ until EMS
arrives. Notify the parent. DO NOT wait for the parent to arrive
before having EMS transport ________ to the hospital.
_____________ ALSO HAS ASTHMA. IF ____ IS HAVING
ANY BREATHING DIFFICULTY, GIVE THE RESCUE
INHALER LISTED BELOW.
1.)
- If ___________ symptoms are increasing in severity OR involve
more than one body system OR ____ complains of difficulty
breathing CALL 911 and have them launch the
helicopter.
- Notify the parent. DO NOT wait for the parent to arrive
before having EMS transport _______________ to the hospital.
- CALL 911 IMMEDIATELY!!! Begin rescue breathing
and CPR until relieved by EMS.
IHP Instructions/504 Accommodations: Food service will be notified of the student’s food allergy (ies).
The student is allowed to eat only the following foods:

 Student is independent in their self-management of food intake.
 Those in manufacturer’s package with ingredients listed & determined to be allergen free by the school nurse.
 Hot lunch menu items selected by parent and registered with School Nurse/Food Services staff.
 Parent/guardian provided cold lunch and snacks.
 The student will eat at the specified allergen free table in the cafeteria. The table is cleaned according to the
guidelines established by the school nurse before and after the student’s meal time.
 The student’s classroom will be designated peanut-free.
 The parent/guardian will be notified ahead of classroom parties.
 The parent/guardian will provide alternative snacks in the student’s backpack daily.
 The parent/guardian will provide alternative snacks to be kept in the classroom for classroom parties.
Grade:
Parent/Guardian:
Parent/Guardian:
Other Emergency Contact:
Preferred Hospital:
Healthcare Provider:
Teacher:
Work Phone:
Work Phone:
Work Phone:
Phone:
Phone:
Bus #:
Cell Phone:
Cell Phone:
Cell Phone:
Fax:
My student may carry their own emergency medications.  YES  NO
My signature indicates my involvement in and agreement with the plan and information provided. I understand:
 I must provide the Liberty School District with an Authorization for Administration of Medication at School Form for this emergency medication signed by myself and my student’s Licensed Healthcare Provider.
 The Medication Authorization Form and emergency care plan must be renewed each school year.
 The School Nurse will work with me to prepare an Emergency Care Plan and/or Individualized Health Plan for my student while at school. This plan will be reviewed and signed by both my student’s Licensed Healthcare Provider and myself.
 I am responsible for providing the current and unexpired prescribed emergency medication for my student in its original container with the prescriptive label attached.
 The School Nurse recommends that we provide back-up emergency medications in the school office. I understand that I do not have to provide back-up medications for the school. If I do not wish to provide back-up medications for the school, my student will be required to demonstrate to the bus driver or school secretary (if driving or driven to school) that they have their medications on their persons as they board the bus or arrive at school. I understand that my student athlete will also have to demonstrate to their coach that they are carrying their emergency medications on their persons in order to participate in athletics.
 If my student receives any emergency medication, I may be required to pick them up from school and be responsible for monitoring them for signs of further breathing difficulty or allergic reaction.
 If my student does not have their emergency medications with them, I understand that I will be notified to pick them up from school or bring their emergency medications to school for them.
 The School Nurse will review with my student his/her knowledge of their health concern, the proper and prescribed timing for using their emergency medications and the correct administration of the emergency medications as prescribed by their healthcare provider.
 That the permission to possess and self-administer emergency medication may be revoked by the principal if it is determined that my student is not safely and effectively self-administering their own medication.
I authorize the school registered nurse and/or nurse trained and delegated school staff to administer my student’s emergency
medications as needed and directed by their licensed healthcare provider.
I authorize the school registered nurse to communicate with my student’s healthcare provider about their medication or emergency
care plan.
Parent Signature: __________________________________________________ Date: ___________________________

I understand that in order to self carry my own rescue medications:
 I will need to keep my rescue medication in a secure place that will be easily accessible to me or to staff in the event of an emergency.
 I will never share this prescribed rescue medication with any other staff or student.
Student Signature: _________________________________________________ Date: __________________________
School Nurse Signature: Sarah Beyersdorf, RN Date: __________________________