Care Plan Childs Name: First Name Last 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 I give permission for my child (name listed above), to carry and administer the medication above themselves at Solon Chabad* Yes*No Parent/Guardian signature: First Name Last Name Date: Month Day Year Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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