Contact Sheet for Children in Daycares, Preschool, School, etc.

Information About Child


Name: ____________ ____________ _______________
Age: _______
Height: ___'___"
Weight: _____
Hair color: _______
Eye color: _______
Male Female
See picture at right
Child reacts to allergens (typically) in this way: _____________________________ ________________________________________________________________________________
Page added (child's reactions to food, etc.)

Allergies


Dairy Eggs Wheat Potato Peanuts Tree nuts Fish Shellfish Soy Other ________, ___________, _______________, ____________
Please note that these allergens can go by different names. For example, albumin can mean "eggs," "lactose" is milk. Alternate names for the above allergens include: ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________
Safe foods: ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________
Being touched/ exposed to an allergen (not just ingesting) can cause an allergic reaction in _______________.
Page added (safe foods included with child, additional allergens, etc.)

Contact Information


Father's name: __________________________
Work phone: _____-____________
Mother's name: __________________________
Work phone: _____-____________
Parents' home phone number: _____-___________
Parents' beeper, cell phone, or other way of contacting: __________________
Neighbor's home work number: ___-_____ (Name: ______________________)
Friend's home work number: ___-_____ (Name: ______________________)
Friend's home work number: ___-_____ (Name: ______________________)
Friend's home work number: ___-_____ (Name: ______________________)
Page added (who to contact)

Treatment if Exposed


Number, in order, of which to contact first.
Parent (numbers listed above)
Family doctor's number: ____-_____________
Pediatrician's number: ____-_____________
Hospital: ____-_____________
Allergist's number: ____-_____________
911
Use EpiPen
(Instructions {where stored, how to administer, etc.}: __________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ___________________)
Page added (treatment information)

This contact form was created by JB, NE, KL and MT and was supplied by Food Allergy Survivors Together (http://www.angelfire.com/mi/FAST). Parents can fill out this sheet with the help and input of their allergist, and append any needed information.