Children With Allergies Form

This form is to be completed by the parent of a child with an allergy and returned to the nominated supervisor. The purpose of collecting this information is to identify children whose parents will need to provide further medical information, in order to provide a safe environment.

Child's Firstname

Child's Surname

Date of Birth

Gender

Allergy

Allergens

Allergy signs and symptoms (PLEASE USE BLANK SPACES FOR ANY ADDITIONAL SIGNS)

Please select as many options as you need

Rubbing face & eyes Agitated or unsettled Redness of skin Rash or hives over body Warmth and swelling of skin

Itchy eyes, sneezing or coughing Itching lips throat or tongue Noisy breathing (Wheezing) Swelling of lips throat & tongue Tightness in chest and/or throat

Difficulty swallowing Shortness of breath Difficulty talking Difficulty breathing Loss of consciousness

Other Symptoms

Has your child ever experienced an anaphylactic reaction?

If yes, please provide details

If your child suffers from a severe food allergy, an individual management plan will be developed in consultation with you. This will include the collection of extensive information.

If your child’s allergy is not severe is there any other information you would like us to be aware of?

Parent's Firstname

Parent's Surname

Date

PLEASE ATTACH A LETTER FROM THE CHILD’S DOCTOR TO THIS FORM.

Please note: Prescription medicine will not be administered if labelled for anyone other than the child named on this form. Please ensure the medication (prescribed and over the counter) is clearly labeled with your child’s name, Date of Birth and dosage, frequency required.

For more information refer to Medical Conditions Policy, Administration of Authorised Medication Policy located in the foyer.