School Child Food Allergy Action Plan
Student Information
Name
Date of Birth
Grade/Class
Parent/Guardian Name
Contact Number
Allergy Information
Allergens
Type of Reaction
History of Anaphylaxis
Asthma
Emergency Action Steps
Symptoms and Actions Required
Medication
Medication Name
Dosage
Instructions
Emergency Contacts
Contact 1 Name
Relationship
Phone
Contact 2 Name
Relationship
Phone
Physician Information
Physician Name
Phone
Parent/Guardian Signature
Date
Physician Signature
Date