CHAMPION KIDZ
(This form is to be used for a diagnosed food allergy only, not a food intolerance)
CHILD’S NAME
DATE OF BIRTH
ALLERGY TO:
*(If no known allergy you can put a N/A and sign the bottom of form)
ASTHMATIC (Check) YES NO
AN INHALER IS TO BE KEPT AT CHILDARE IF PRESCRIBED, IF TOO YOUNG FOR INHALER
BREATHING MACHINE IS TO BE BROUGHT INTO CHILDCARE
My child may experience one or more of the following:
SYMPTOMS: (Please check)
Itching & Swelling of the lips, tongue or mouth
Itching and/or sense of tightness in the throat, hoarseness, and hacking cough
Hives, itchy rash, and/or swelling abut the face or extremities
Nausea, abdominal cramps, vomiting, and/or diarrhea
Shortness of breath, repetitive coughing, and/or wheezing
”Thready” pulse, “passing out”
ACTION:
If ingestion is suspected, give
Medication/dose
and immediately!
Course of action
AN EPIPEN IS TO REMAIN AT CHILDCARE IF PRESCRIBED
PHYSICIAN’S NAME PHONE NUMBER
DATE
PHYSICIAN’S SIGNATURE:
I give permission for Champion Kidz Childcare LLC staff to administer the above medication if necessary, and follow the course of action as directed by the above-named physician.
DATE PARENT’S SIGNATURE:
FOR CHILDREN WITH MULTIPLE FOOD ALLERGIES, USE ONE FORM FOR EACH FOOD