Light of Christ Catholic Schools

7th & 8th Academy/High School

Allergy Management Plan and Parent Authorization for Antihistamine

(for non-anaphylactic allergies)

(Effective Date: Current School Year______)

Child’s Name

/

DOB

/

Grade

Parent(s)/Guardian(s) /

School/Teacher

Parent/Guardian Phone Numbers: Home: Work: Cell:

Emergency Contact (Other Than Parent/Guardian)

/

Emergency Phone

Physician/Phone Hospital/Phone

ALLERGIES (Check all that apply):

_____ Animals_____ Bee/Insect Stings_____ Dust/Dust Mites_____ Latex

_____ Molds_____ Pollen_____ Strong Odors/Fumes

_____ Foods: ______

_____ Medications: ______

_____ Other: ______

Will this Child have an Antihistamine at School? ____Yes ____ No

If “Yes”: (a) Complete next page; and

(b) Provide medication to school

HISTORY

  1. Does your child know what allergies he/she has? _____ Yes_____ No
  2. Does your child know when to contact an adult for help? _____ Yes_____ No
  3. Has your child gone to the emergency room for allergy symptoms? _____ Yes _____ No
  4. Has your child had a life threatening anaphylactic allergic reaction? _____ Yes _____ No

SIGNS OF AN ALLERGIC REACTION --Circle allergy symptoms your child has had:

  • Eyes: red, watery, itchy
  • Nose: runny, stuff, sneezing
  • Mouth: itching, swelling of lips, tongue, or mouth
  • Heart: weak pulse, passing out, increased heart rate
  • Throat: itching, tightness, hoarseness, hacking cough, difficulty swallowing
  • Skin: hives, itchy rash, swelling of the face or extremities, or other areas
  • Stomach: nausea, stomach cramps, vomiting, diarrhea
  • Lungs: shortness of breath, coughing, wheezing, difficulty breathing

SCHOOL PLAN OF ACTION (Please indicate next steps if child shows signs of an allergic reaction):

1.______

2.______

3.______

AUTHORIZATION FOR ANTIHISTAMINE

Medication Name: ______Strength: ______Dose: ______

Instruction for Use: ______

Medication Side Effects: ______

Other Information Staff Should Know About Student and This Medication: ______

______

AUTHORIZATION:

  • I give permission to Light of Christ Catholic School personnel to administer this medication. I understand that administration of this medication may not necessarily be done by a nurse.
  • I will notify the school immediately if my child’s health status changes, or this medication is discontinued.
  • I give permission to School personnel to contact the physician as needed; and that medication/health information may be shared with staff who need to know.
  • If I indicate below that my child will self-administer his/her medication, I verify that my child has received training on how/when to administer this medication, and continuously secure its access from others.

1. I have read and understand the information listed above (circle one): YES NO

2. I authorize school personnel to administer this medication to my child (circle one): YES NO

(Or)

I authorize my child to self-administer this medication (circle one): YES NO

Parent______Date: ______

FOR ELEMENTARY OFFICE USE: Copy Provided To: ___Classroom Teacher ___PE Teacher ___Other/______Other/______