Allergies - Emergency Action Plan

Allergies - Emergency Action Plan

HCS Health Services
Student Information
Student Full Name
Date

MonthDayYear
Current Grade Level
School
Teacher
Does your student ride a bus?
Morning Bus Number
Evening Bus Number

Allergy Information
Student is allergic to
Please list all allergies

Emergency Contact Information
Contact 1
Full Name
Contact 1 Full Name
Phone Number - 1
Contact 1 Phone 1
Phone Number - 2
Contact 1 Phone 2
Phone Number - 3
Contact 1 Phone 3
Contact 2
Full Name
Contact 2 Full Name
Phone Number - 1
Contact 2 Phone 1
Phone Number - 1
Contact 2 Phone 1
Phone Number - 1
Contact 2 Phone 1

Signature and Understanding
I understand and agree that information in this Emergency Action Plan will be shared with appropriate school staff.
Are you able to provide your signature on this form?

Yes, I am able to provide my signature on this form.No, I am NOT able to provide my signature. Note: You will need to come to the school and sign in person.
Parent / Guardian Signature

Clear
Today's Date

MonthDayYear
Should be Empty: