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Child Information
Child's Name
Date of Birth
Parent/Guardian Name
Parent/Guardian Phone Number
Allergy Information
List all food allergies
Reaction History
Treatment Plan
Medications Required
Dosage Instructions
Administration Procedures
Emergency Action Plan
Symptoms to Look for
First Aid Procedures
Emergency Contact Name
Emergency Contact Phone Number
Parent/Guardian Sign Off
I have provided complete and accurate information regarding my child's food allergies
I authorize the staff to administer medication and follow the emergency action plan
Parent/Guardian Signature
Date