Dear Parent,
We take allergies very seriously and want to do our best to prevent allergic reactions and to be prepared should there be an allergy emergency. To optimize care for your child, we would appreciate the prompt submission of the following:
Food Allergy and Anaphylaxis Action Plancompleted and signed by your child’s physician. This form is important to the care of your child as itprovidesguidance in the event that your child experiences an allergic reaction while at school.
Two (2) Epinephrine auto-injectors(such as EpiPen, AUVI-Q, or other epinephrine-injection device) with the pharmacy label containing the student’s name on it. Please ensure these auto-injectors will not expire until after June 2018.
Any medications listed on your child’s physician-signed Food Allergy and Anaphylaxis Action Plan. This may include an albuterol inhaler and/or Benadryl. If you use a generic brand of Benadryl, make sure it is Diphenhydramine HCL and not another allergy medicine as there are several different allergy medicines for children now. If your physician recommends other allergy medication, then it should be specified in the Food Allergy and Anaphylaxis Action Plan.
A photo-permission form, which gives us permission to take a photograph of your child to be displayed in the child’s classroom, in the office, and in staff rooms. This allows the staff to recognize your child and his/her allergies.
Table Preference form, which informs us of your preference for your child’s seating during lunch.
We welcome the opportunity to meet with you in person to discuss your child’s allergies and how we can optimize your child’spersonalized health management plan at school.
Sincerely,
School Nurse
After-Hours Medication Planning
Attention Parent:
If your child participates in afterschool activities, be aware that the emergency medicines (Epipens, inhalers, etc.) that are stored at school may not be easily accessible at all hours of these programs. We encourage you to talk with the administrators of the program in which your child is participatingso that a plan may be established should your child need his/her emergency medication in the after-school situation.
Emergency medication should be accessible during all activities in which your child participates. This may mean providing the program with a second set of emergency medication.
If you have any questions or would like to talk more about this or other at-school medical issues, please don’t hesitate to reach out to me.
Thank you,
School Nurse
Photography Permission Agreement
Date______
I give permission for my child ______to be photographed at Brownsville Elementary School in order that he/she can be easily identified as having a life-threateningmedical issue.
Signature______
For schools with a nut-free table
Dear Parent:
We offer a Nut Free Table in our cafeteria for those students who are allergic to nuts. Seating is limited to those students that are allergic to nuts and to classmates who have no nut products in their lunch.
My child’s name______
Please check one of the following, and return this form to school.
______I request that my child always sit at the Nut-Free Table. I understand that he/she will be able to ask a friend to join him/her if they have no nut products in his/her lunch.
______I request my child NOT sit at the Nut-Free Table.
______I request my child be permitted to decide if he/she wants to sit at the Nut-Free Table.
Parent Signature______
Thank you,
School Nurse
For schools with a nut table
Dear Parent:
We offer a Nut Table in our cafeteria for those students who wish to bring lunch containing nuts. We do this in an effort to protect children with nut allergies while not limiting the freedom of other children to eat nut products. Students who are not eating a nut product but wish to sit at the nut table may do so pending availability.
My child’s name______
Please check one of the following and return this form to school.
______I understand that my child will sit at the Nut Table when he/she is eating a nut-containing lunch.
______I request that my child NEVER sit at the Nut Table as my child has a nut allergy.
Parent Signature______
Thank you,
School Nurse