Allergy Care Plan

New regulations from the Kentucky Cabinet for Families and Children Division of Childcare require the posting of a quick reference allergy care plan that will be easily seen and understood by all staff who may interact with your child. Please answer the following, which will be posted with your permission. You may also need to complete the Blanket Release Rescue/Emergency Medication Form to be kept with medication and in the school office.

Student Allergy Care Plan

Essential allergy care information for quick reference by school personnel.

X/Twitter

This field is for validation purposes and should be left unchanged.

Child's Name(Required)

First Last

Basic Description of Allergen(Required)

Severity of Allergy(Required)

Mild

Moderate

Severe

Symptoms Child Will Exhibit(Required)

Medication prescribed?(Required)

Yes

No

Medication(Required)

Name and dosage, or n/a

Treatment Plan(Required)

Permission to post(Required)

I give my permission for this information to be posted near where food is served in the classroom and school kitchen. If necessary, an additional Blanket Release for Emergency Rescue/Medication Form will also be kept with student records and medication.

Yes

No

Name of Person Filling Out This Form(Required)

First Last

Signature(Required)

Please try to be legible: your signature is required for Kentucky child care licensure purposes.