Free template · Health and safety

Allergy action plan

A plan for one child with a serious allergy: what the child is allergic to, signs of a reaction, what staff do for mild and severe symptoms, and the doctor's sign-off.

Download PDF Word version

What's in it

What the allergy action plan covers

At the top: Please have your child's doctor complete and sign this plan, or attach the plan your doctor already uses. We keep a copy with your child's medicine and with their group's leader. This is a sample form, not medical advice.

Child

Full name
Date of birth
Weight
Program and group
Attach a recent photo

Allergy

Child has asthma (higher risk of a severe reaction)
Child can tell an adult when they're having a reaction
Allergic to
Past reactions (what happened and when)

Mild symptoms

For example: itchy mouth or nose, a few hives, mild itching. The doctor fills in what staff should do. If staff aren't sure whether symptoms are mild or severe, they follow the severe plan.

What staff should do
Medicine (name and dose), if any

Severe symptoms

For example: trouble breathing, wheezing, throat tightness, swelling of the tongue or lips, repeated vomiting, many hives, pale or blue skin, fainting, or symptoms in more than one part of the body. Give epinephrine as the doctor directs below. Call 911 after any dose of epinephrine, even if the child seems better, then call the parent. Keep the child lying down with legs raised, or sitting up if they're struggling to breathe. Don't let them stand or walk.

What staff should do
Epinephrine (brand and dose)
When to give a second dose, if symptoms continue or return
Other medicine (name and dose)

Epinephrine

Families provide two unexpired auto-injectors. A child carries their own only if the doctor approves it below.

Doctor approves: child may carry their own epinephrine auto-injector
Staff carry the auto-injectors
Where they're kept during the program

Doctor

Doctor's printed name
Doctor's signature
Phone
Date

Parent or guardian permission

I give permission for program staff to follow this plan and give my child the medicine listed above, and to share this plan with staff who care for my child.

Parent or guardian printed name
Parent or guardian signature
Emergency phone
Date

Free to use and change, but not legal or medical advice. Check your state's licensing rules and your insurer's requirements, and have a lawyer review any consent or waiver language.

Tips

How to use it well

Train every staff member who works with the child on the plan and on using the auto-injector, before the first day.
Keep the plan and the medicine together, and take both on field trips, swim days and bus rides.
Check expiration dates on the medicine at the start of each session.
Check your state's licensing rules and your insurer's requirements for medication training and storage.

Rules on ratios, medication and reporting vary by state. See your state in our state-by-state rules for youth programs.

FAQ

Questions, answered

What is an allergy action plan?

A short plan, signed by the child's doctor, that tells staff what the child is allergic to, which symptoms to watch for and exactly what to do, including when to give epinephrine and call 911.

Can we use the plan from the child's doctor instead?

Yes. Many doctors use their own form. Accept any plan signed by the child's doctor that covers the allergy, the symptoms, the medicine and dose, and when to call 911.