School Allergy Action Plan
Student Information
Student Name
Date of Birth
School
Grade/Teacher
Parent/Guardian & Emergency Contact
Parent/Guardian Name
Phone
Emergency Contact
Emergency Phone
Allergen(s)
List all allergens
Symptoms of Allergic Reaction
Area
Symptoms
Mouth
Skin
Gut
Throat
Lung
Heart
Treatment
Medication(s) at School
Medication Instructions
Location of EpiPen/Auto-Injector
Healthcare Provider
Provider Name
Provider Phone
Signatures
Signature
Date
Parent/Guardian
Healthcare Provider
School Nurse