2016 – 2017 EMERGENCY PLAN FOR DAVIDSON GREEN
SCHOOL STUDENTS WITH ALLERGIC REACTIONS
Student’s Name__________________________________________________________
This student has allergies:
YES (Does Have)
NO (Does NOT Have)
If this student DOES NOT have allergies, sign and date here:
By checking this box, I authorize the below typed name to stand as my electronic signature, and submit
this form as my intention and will.
Parent/Guardian signature_____________________________________________Date_________________
(You do not have to fill out the remainder of this form.)
Parent/Guardian_______________________________ Home #________________ Cell#_____________
Physician_______________________________________________ Phone#_________________________
Family member or friend aware of child’s condition:
Name_______________________________________ Phone#_________________ Cell#_____________
My child is at risk for a life-threatening allergic reaction:
Yes
No
My child’s allergy was identified through allergy testing:
Yes
No
My child had his/her most recent reaction on the following date: _____________________
My Child has an allergic reaction to:
Allergy trigger
(e.g. peanuts, bees,
latex, beans,
strawberries, etc.)
Life
threatening?
(YES or NO)
Allergic reaction and
symptoms
(e.g. shortness of
breath, coughing,
swelling, vomiting,
dizziness, etc.)
Circumstances
reaction will
occur
(e.g. skin contact,
ingestion,
inhalation, etc.)
Treatment
If an allergic reaction would occur at school, personnel will administer first aid (remove stinger, apply ice,
observe for 15 minutes and record side effects). We will follow your suggested treatment listed above. You
will be notified of the incident immediately. Please indicate which further treatment a health care provider is
recommending for your child:
Call 911 Immediately
Administer medication: Name ________________________ Dosage _______________________
(Please fill out a medication authorization form).
Other ___________________________________________________________
**Please note that 911 will be called if an Epipen is given or if your child is demonstrating
symptoms of a systemic allergic reaction**
I hereby give permission for designated school staff to give this medication to my child according to the directions stated above and
for a school official to contact my child’s physician if necessary.
I further agree to hold harmless the Davidson Green School Board of Directors, agents, and all employees who are acting within the
scope of their duties in any and all claims arising from the administration of this medication at school.
I agree to notify the school in writing at the termination of this request or when any change in the above order is necessary.
By checking this box, I authorize the below typed name to stand as my electronic signature,
and submit this form as my intention and will.
Parent/Guardian signature_____________________________________________
Date____________
Physician Signature __________________________________________________ Date____________
School Official Signature _____________________________________________
Date ____________