ALLERGY ACTION PLAN (REQUIRED FOR STUDENTS …

1 of 3 CTY ALLERGY ACTION plan 2018 Complete this form by May 15th and upload to the Allergies & Asthma Section of your child s CampDoc CTY Medical form. You may submit an ALLERGY ACTION plan the student uses during the school year if it is signed by a physician in lieu of this form. Form must be signed by treating physician within last 2 years. ALLERGY ACTION plan (REQUIRED FOR STUDENTS BRINGING EPINEPHRINE) (This information will be shared with all staff working with your child.) CTY Student ID: _____ Student s Name: _____ Site: _____ Session: Session 1 Session 2 Both Weight: _____lbs/kg Date of Birth (mm/dd/yyy): _____ ALLERGY TO: _____ Does your child have asthma? Yes No (If yes, there is a higher risk of reaction.) TREATMENT INFORMATION: Note: Inhalers/bronchodilators and antihistamines are not to be depended upon to treat a severe allergic reaction (anaphylaxis) Use epinephrine.

1 of 3 CTY ALLERGY ACTION PLAN 2018 Complete this form by May 15 th and upload to the Allergies & Asthma Section of your child’s CampDoc CTY Medical form. You may submit an Allergy Action Plan the student uses during the school year if it is signed by a physician in lieu of this form.

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  Plan, Action, Allergy, Allergy action plan

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