Form Overview This form is to be used by families to provide information about any anaphylactic allergies a child may have. Which Child Care Advisor have you been working with (if unsure, select "I can't remember")? *Please select your Child Care Advisor...ClairHediKatyeMargaretMeganSandraI can't rememberYour Child's Full Name *Allergy DetailsPlease 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 bodyHivesOngoing Instructions:What to avoid, practices to follow, if self-administration is required, etc.Does your child have an EpiPen Auto-Injector?YesNoExpiration date of AutoInjector (EpiPen) *Location of Auto-Injector at the Home Child CareParent/Guardian Contact InformationPlease 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? *YesNoIf 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 hereYour browser does not support e-Signature field.Signature of Child Care ProviderStart signing your signature hereYour browser does not support e-Signature field.Today's Date: *SubmitPlease do not fill in this field.