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Dufferin-Peel Catholic DSB
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Upper Grand District School Board
Wellington Catholic District School Board
School
Grade
Student Last Name
Student First Name
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Form type
Anaphylaxis
Inhaler
Diabetic
Other
Anaphylaxis: (Emergency Intervention Release)
Allergies: List any allergies which may result in anaphylactic shock
Symptoms: List any known symptoms which may be a precursor to anaphylaxis shock
Location of EpiPen
Inhaler
Symptoms: List any known symptoms
Location of Inhaler
Diabetes (Diabetes Hypoglycemia Emergency Action Plan)
Signs and Symptoms
Sweating
Trembing
Dizziness
Mood changes
Hunger
Headaches
Blurred vision
Extreme tiredness/paleness
Other, please specify
Location of Sugar Treatment
With Student
Other, please specify
Other Information
Other Requirements: e.g. Feeding tube, oxygen
Emergency Contact Information
Individual #1
Name
Relation
Phone
Individual #2
Name
Relation
Phone
Submitted by
I acknowledge that transportation procedures will apply.
Last Name
First Name
Email
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