Anaphylaxis Alert and Permission Form

Form Overview

This form is to be used by families to provide information about any anaphylactic allergies a child may have.

Who is your Child Care Advisor (if unsure, select "I don't know")? *

Your Child's Full Name *

Allergy Details

Please complete all required fields.

Allergy Description *

Symptoms (please select all that apply): *Tingling, itching, swellingDifficulty breathingWeakness or dizzinessThroat tightnessChest tightnessStomach cramping, vomitingDifficulty swallowingSense of fearFeeling faintWheezing, coughingFlushing of the face and bodyHives

Ongoing Instructions:What to avoid, practices to follow, if self-administration is required, etc.

Does your child have an EpiPen Auto-Injector?YesNo

Expiration date of AutoInjector (EpiPen) *

Location of Auto-Injector at the Home Child Care

Parent/Guardian Contact Information

Please complete all required fields.

Parent/Guardian *

Parent/Guardian Phone *

Parent/Guardian Email Address *

Emergency Contact *

Emergency Contact Phone *

Is your child care provider with you as you complete this form? *YesNo

If yes, they can sign the form now. If no, we will send them a copy of this form to sign later.

Name of the Provider (or the alternate Provider) *

Signature of Parent / Guardian *

Start signing your signature here

Signature of Child Care Provider

Start signing your signature here

Today's Date: *

Please do not fill in this field.

Children’s Village of Ottawa-Carleton
333 Churchill Avenue,
Ottawa, ON K1Z 5B8

+1 (613) 725-2040

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