Anaphylaxis Safety Plan - Mountain Christian School

Anaphylaxis Safety Plan

Anaphylaxis Safety Plan

Student's Full Name

Student's Birthdate

Gender

Male

Female

Student's Healthcare #

Date of Plan

Physician's Name

Physician's Phone #

Reason for a plan

Symptoms and Additional Information

Parent / Guardian (1st Emergency Contact)

Full Name

E-Mail

Cell Phone

Work Phone

Parent / Guardian (2nd Emergency Contact)

Full Name

E-Mail

Cell Phone

Work Phone

Other if unable to reach Parent/Guardian

Full Name

Phone Number

Epi-Pen Available at School

Yes

No

Expiry date of epi-pen currently on hand

Location

Reason

Please note that it is the policy of Mountain Christian School to call 911 in the event of any incident occurring which leaves the supervising staff member in question of the health or safety of any student.

If any changed required to the above plan, please click here

Parent / Guardian Full Name

Date

Signature

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