Allergy Plan

Parent/Guardian First Name:*
Parent/Guardian Last Name:*
Phone Number:*
Alternate Phone Number:
Email Address:*
Child's Name:*
Date of Birth:*
Date of Plan:*
MM slash DD slash YYYY
Please list child's allergen(s) and reaction(s).
Allergent Reaction

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Physician Name:*
Physician Phone Number:*
Emergency Contact:*
Cell Phone:*
Other Phone:
Brief description of child's allergies and reactions:
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If child displays the following symptom: Take the following action:

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EBS Children’s Institute staff will do its part to be continually aware of child’s specific allergy. However, it Is not possible to percent 100% of all accidental exposures in a center which is frequented by such a large group of clients and families each week. By signing below you understand that EBS Children’s Institute of Oxford will not be held liable for any reactions that a child has to contact with our clinic environment.

Before serving your child, EBS will need a copy of your child’s emergency allergy plan. If the emergency plan requires medication (EpiPen, inhaler, etc.), we require parents to stay on the premises for the duration of the session.
Relationship to Child:*
Date:*
MM slash DD slash YYYY

Allergent	Reaction

If child displays the following symptom:	Take the following action: