TO BE COMPLETED BY PARENT                                                                                                                              [TO BE POSTED, FOLLOWING PARENTAL CONSENT]

Student's Name___________________________________________________________________________________________________________
 
 

  • ALLERGY - DESCRIPTION
This student has a DANGEROUS, life-threatening allergy to the following:
_________________________________________
_________________________________________
_________________________________________

and all substances containing them in any form or amount, including the following kinds of items:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
 

 
 
 
 

Place Student's Photo Here

The key to preventing an emergency is ABSOLUTE AVOIDANCE of these allergens at all times. ___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
______________________________________________________________________________________________
 

SYMPTOMS FOLLOWING EXPOSURE TO A PARTICULAR MATERIAL CAN INCLUDE:
 

  • hives and itchiness on any part of the body;
  • nausea, vomiting, diarrhea;
  • difficulty breathing or swallowing;
  • panic or sense of doom;
  • throat tightness or closing.
  • swelling of any body parts, especially eyelids, lips, face or tongue;
  • coughing, wheezing or change of voice;
  • fainting or loss of consciousness;
  • other, please specify .

 

EMERGENCY MEASURES

If the ambulance has not arrived in 10-15 minutes, and breathing difficulties are present, administer a second Epipen® (epinephrine).
I agree that the school may post my student's picture, take the Emergency Measures and that this information will be shared, as necessary, with the staff of the school and health care providers.

Date _____________________              Parent's Signature _______________________________________________________

POST IN APPROPRIATE LOCATIONS WITHIN THE SCHOOL



This information provided courtesy of the Calgary Allergy Network web site at https://calgaryallergy.ca.This form is part of the Calgary Board of Education Severe Allergies policy.


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