Student Allergy and Emergency Action Plan
Student Information
Student Name
Date of Birth
School
Grade
Parent/Guardian Contact
Parent/Guardian Name
Relationship
Phone (Main)
Phone (Alternate)
Physician Contact
Physician Name
Phone
Allergy Information
List All Allergies (food, medication, insect, other):
Describe Reaction(s):
Usual Treatment Given:
Emergency Action Plan
Symptoms to watch for:
Actions to take during an allergic reaction (include medication and dosage):
When to call emergency services:
Medications at School
Medication(s) to be kept at school (name, dose, route, location):
Does student know how to self-administer? (Yes/No):
Parent/Guardian Signature
Date
Physician Signature
Date