RCJTC AnaphylaxisRequest

District

School

Grade

Student Last Name

Student First Name

Gender

Birth Date

Student ID

Alternate ID

Anaphylaxis Emergency Treatment Plan

Student Photo

Emergency Contacts

		Name:	(H)	(W)	(C)
	1.

		Name:	(H)	(W)	(C)
	2.

		Name:	(H)	(W)	(C)
	3.

Student has a potentiall life-threatening allergy (anaphylaxis) to the following:

Peanut

Tree Nuts

Wheat

Egg

Milk

Latex

Insect Stings (bees/wasp)

Other:

Medical:

Parent/Guardian grants permission for a copy of this form to be given to their child's driver, where applicable.
All drivers have First Aid/CPR and EpiPen® training.

Signs and Symptoms

A person experiencing an anaphlyactic reaction might have one of the following symptoms:
F.	Face: rash, itchiness, redness, swelling of face and tongue.
A.	Airway: trouble breathing, swallowing or speaking.
S.	Stomach: stomach pain, vomiting, diarrhea.
T.	Total: hives, rash, itchiness, swelling, weakness, pallor (palenesss) sense of doom, loss of consciousness.

Treatment: Think - A.C.T

Administer the epinephrine auto injector (EpiPen®) IMMEDIATELY, at the first sign of a reaction, in conjunction with the child's contact with their life threatening allergen.

Administer the injection in the lateral (outer) location on the thigh. Inject and count for 10 seconds. Remove the EpiPen®, check needle is showing and massage area for 10 seconds.

A second dose may be administered 10 - 15 minutes or sooner, if symptoms have not improved or worsened.

Call 911. When informing the dispatcher use the term 'ANAPHYLACTIC' reaction.

Transport to hospital by ambulance. Student must go to the hospital even if symptons are mild or have stopped. Call parents/guradians.

Submitted by I acknowledge that transportation procedures will apply.

Last Name

First Name