Care Plan

Care Plan
Childs Name:
First NameLast Name
Age:
Food Allergies?
YesNo
Foods your child is allergic to:
Can your child eat foods made in the same facility?
Please add any other details that may be helpful:
Please list precautions needed, i.e child need to be in a different room.
Other Allergy/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 meet. EpiPens/medications must be brought in at least 2 weeks before your child begins the program and please enclose a photo of your child.
Name of medication:
Exact dosage:
To be administered at the following times:
Permission:
I give permission for my child (name listed above), to receive the above medication at Solon Chabad.
Yes
Parent/Guardian signature:
First NameLast Name
Date:
MonthDayYear
Should be Empty:

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Medication: