Care Plan

Child's Name:
First Name Last Name
Allergies
Please list allergies.
Symptoms to watch for:
Actions to take:
Please add any other details that may be helpful, such as precautions needed & severity of allergy.
Medical Conditions
Please explain medical condition.
Symptoms to watch for:
Action to take:
Medication:
EpiPen?

Yes*No
Medication?

Yes*No
*If yes, please email [email protected] to arrange a time to drop off the EpiPen or medication BEFORE camp begins.
Name of medication:
Exact dosage:
To be administered at the following times:
Please submit a photo of your child:
Permission:
I give permission for my child (name listed above), to receive the above medication at Solon Chabad.*

Yes
I give permission for my child (name listed above), to carry and administer the medication(s) above themselves at Solon Chabad*

YesNo
Parent/Guardian signature:
First Name Last Name
Date:

Month Day Year
Should be Empty:

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Allergies