Food Allergy Emergency Care Plan

Paper Form

To simplify the form submission process, it is preferred you complete the online form below. If you would still prefer to submit mailed forms, you may download this form in a printable format here and mail it to your respective conference’s registrar along with any additional forms or payment. Thank you!

Begin Online Form

Paper forms are still available upon request.

Conference

Conference(s) you would like to submit this form to*
Labor Day Family
Post High
11/12
9/10
7/8
4/5/6

Information

Full Name*

Email*

Date of Birth*

Known Food Allergies*

Common signs of an allergic reaction (this is not an exclusive list of symptoms)
MOUTH Itching; tingling; swelling of lips, tongue or mouth
THROAT Itching and/or a sense of tightness in the throat, hacking cough
SKIN Hives, itchy rash, swelling about the face or extremities
GI Nausea, vomiting, abdominal cramps, diarrhea
LUNGS Shortness of breath, repetitive coughing, wheezing
HEART “Thready” pulse, dizziness or fainting

During an allergic reaction his/her typical symptoms are:

NOTE: Different symptoms may occur with any reaction and severity of symptoms can change rapidly. A high level of suspicion needs to be maintained for any symptoms exhibited by someone with food allergies. ACT QUICKLY!!

If ingestion is suspected and/or symptoms are present, IMMEDIATELY DO THE FOLLOWING:

1. TREATMENT (include exact doses when applicable)

2. CALL 911 & THE CAMP NURSE

3. CONTACT PARENT/GUARDIAN/DESIGNEE

Emergency Contact Information

Parent/Guardian Emergency Contact 1 Name*

Phone (Home)

Phone (Work)

Phone (Cell)

Parent/Guardian Emergency Contact 2 Name*

Phone (Home)

Phone (Work)

Phone (Cell)

Emergency Contact (if Parent/Guardian not available)/Relationship/Telephone Number:*

Healthcare Provider Name*

Healthcare Provider Phone Number*

Date*

Please select at least one conference before submitting the form.