What this daycare allergy form is for
The sheet helps staff prevent exposure and find the child's individualized response information quickly. It is a companion to, not a replacement for, a clinician-signed emergency action plan or medication authorization required by your program or jurisdiction.
When to use it
Complete it before the child attends or eats program food. Review it whenever symptoms, severity, substitutions, emergency contacts, medication, or clinician instructions change and on the review schedule set by the plan.
Who completes it
The parent or guardian provides the history, substitutions, contacts, and authorization. A health professional should supply clinical instructions when required; program staff review prevention steps and medication location.
Fields included in the template
The printable form groups the work into 4 clear sections. Use the field list to compare it with your program's current packet and any official document you must keep.
Allergy details
- Allergen
- Type of exposure
- Known symptoms and severity
Response
- Emergency response steps from current plan
- Medication, dose reference, and location
- Physician and phone
- Emergency contact and phone
Prevention
- Dietary substitutions
- Cross-contact and activity precautions
Authorization and review
- Parent authorization and signature
- Provider review signature
- Plan review date
12 structured field groups power both this preview and the downloadable PDF.
How to complete the form
- 1
Name each allergen and indicate food, skin, inhaled, medication, or other exposure routes.
- 2
Describe the child's known symptoms and severity in concrete terms rather than guessing at a diagnosis.
- 3
Attach the current emergency action plan and copy its response sequence accurately.
- 4
Identify medication, storage location, expiration checks, physician, and emergency contacts.
- 5
List safe substitutions, obtain signatures, and schedule the next review.
What a completed record might capture
A child's tree-nut allergy record lists ingestion and cross-contact as exposure routes, identifies hives and breathing difficulty as documented symptoms, points staff to the clinician plan, records the epinephrine location, and names two safe snack substitutions.
The names and details in this example are fictional. Use factual, program-specific information on the actual form.
Common mistakes to catch
- Writing food allergy without naming the allergen
- Inventing response instructions instead of attaching the clinician plan
- Storing medication somewhere different from the location on the form
- Using the same utensils for an identified substitution
- Failing to update contacts or medication expiration information
Storage, review, and follow-up
Keep the current plan accessible to trained staff while protecting medical privacy. Follow licensing and health-professional guidance for classroom copies, transport, training acknowledgment, medication logs, superseded plans, and post-enrollment retention.
This form does not provide medical advice. Follow the child's clinician-approved plan, medication orders, emergency instructions, and applicable child care rules.