Parental Statement CHILD’S SPECIFIC SIGNS AND SYMPTOMS OF A CHILD’S SPECIFIC SIGNS AND SYMPTOMS OF A LIFE THREATENING ANAPHYLACTIC REACTION: (specific THREATENING ANAPHYLACTIC REACTION: (specific to to the child, e.g. wheezing and itchy skin) the child, e.g. inability to breathe, sweating) DESCRIPTION OF PROCEDURE TO FOLLOW IF CHILD DESCRIPTION OF PROCEDURE TO FOLLOW IF CHILD HAS A LIFE-THREATENING ANAPHYLACTIC REACTION: HAS A NON-LIFE THREATENING ANAPHYLACTIC REACTION: STEPS TO REDUCE RISK OF EXPOSURE TO CAUSATIVE AGENT/ALLERGEN: (e.g. nut-free environment) ADDITIONAL NOTES (if applicable): (e.g. use of other emergency allergy medication(s) to implement the emergency procedures) I (parent/guardian) hereby give consent for my child (child’s name) to (check all that apply): carry their emergency allergy medication in the following location (e.g. blue fanny pack around their waist): self-administer their own medication in the event of an anaphylactic reaction AND/OR I (parent/guardian) hereby give consent to any person with training on this plan at the home child care premises to administer my child’s epinephrine auto-injector and/or asthma medication and to follow the procedures set out in my child’s Individualized Anaphylaxis Plan and Emergency Procedures. Parent/Guardian initials: ________ EMERGENCY CONTACT INFORMATION Contact Name Relationship to Child Primary Phone Number Additional Phone Number HEALTHCARE PROFESSIONAL CONTACT INFORMATION: (optional) Contact Name Primary Contact Number SIGNATURE OF HEALTHCARE PROFESSIONAL (optional) Date: X SIGNATURE OF PARENT/GUARDIAN (required) Print name: Relationship to Child: Date: X
CHILD’S SPECIFIC SIGNS AND SYMPTOMS OF A THREATENING ANAPHYLACTIC REACTION: (specific to the child, e.g. wheezing and itchy skin) CHILD’S SPECIFIC SIGNS AND SYMPTOMS OF A LIFE THREATENING ANAPHYLACTIC REACTION: (specific to the child, e.g. inability to breathe, sweating) DESCRIPTION OF PROCEDURE TO FOLLOW IF CHILD HAS A NON-LIFE THREATENING ANAPHYLACTIC REACTION: DESCRIPTION OF PROCEDURE TO FOLLOW IF CHILD HAS A LIFE-THREATENING ANAPHYLACTIC REACTION: STEPS TO REDUCE RISK OF EXPOSURE TO CAUSATIVE AGENT/ALLERGEN: (e.g. nut-free environment) ADDITIONAL NOTES (if applicable): (e.g. use of other emergency allergy medication(s) to implement the emergency procedures) Parental Statement I (parent/guardian) hereby give consent for my child (child’s name) to (check all that apply): carry their emergency allergy medication in the following location (e.g. blue fanny pack around their waist): self-administer their own medication in the event of an anaphylactic reaction AND/OR I (parent/guardian) hereby give consent to any person with training on this plan at the home child care premises to administer my child’s epinephrine auto-injector and/or asthma medication and to follow the procedures set out in my child’s Individualized Anaphylaxis Plan and Emergency Procedures. Parent/Guardian initials: ________ EMERGENCY CONTACT INFORMATION Contact Name Relationship to Child Primary Phone Number Additional Phone Number HEALTHCARE PROFESSIONAL CONTACT INFORMATION: (optional) Contact Name Primary Contact Number SIGNATURE OF HEALTHCARE PROFESSIONAL (optional) X Date: SIGNATURE OF PARENT/GUARDIAN (required) Print name: Relationship to Child: X Date: