Special Care Plan for Allergies

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Student Information

Child's NameEnter Full Name

Nickname

Date of Birth

Emergency Contact Information

Parent/Guardian Name

Phone NumberBest phone to reach you in case of emergency

Primary Healthcare Provider

Physician NameEnter Full Name

PhoneEnter the best phone number to contact you at

Facility/Clinic Name

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Health Insurance Information

Insurance Company

Policy HolderEnter policy holder's name

Policy Holder Date of Birth

Insurance ID

Group Number

Group Name

Health/Allergy Information

Description of AllergiesPlease enter all relevant allergies

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Description what signs/or symptom look like?Please enter all relevant information

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Description known triggersPlease enter all relevant information

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Description of treatmentPlease enter all relevant information

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Description side effects: i.e.: No peanut products allowedPlease enter all relevant information

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Signature

Parent/Guardian Signature

(Sign Here)

Clear Signature

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