Free printable allergy form for daycare.

For a child with an allergy or a food restriction. The doctor fills in the action plan, and a parent signs.

It prints at the top of the form.

Allergy and food restriction form

Program
Child’s name
Date of birth
Room or group
Parent’s phone
Allergies
What the child is allergic toWhat a reaction looks likeHow serious it can be

Food restrictions

Foods the child must not eat
Foods to give instead
Other food needs, such as religious or family choices

Action plan, filled in by the doctor

Signs of a mild reaction
What staff do for a mild reaction
Signs of a severe reaction
What staff do for a severe reaction
Medicine name and dose
Where the medicine is kept

Medicine prescribed:Epinephrine auto-injectorAntihistamineInhalerNone

Staff follow this plan as written, and call 911 in an emergency.

Signatures

Doctor or health care provider
Doctor’s phone
Doctor’s signature
Date
Parent or guardian signature
Date

Free printable form from bloomily.app/tools/forms

How to use this form

  1. Ask the family to take the form to the child’s doctor.
  2. Read the action plan with every adult who cares for the child.
  3. Keep copies in the room, in the kitchen and in the emergency bag.
  4. Keep any medicine where staff can reach it fast, and take it on trips.
  5. Ask for a new form each year, and whenever anything changes.

Check your state’s rules

Some states require a written care plan from a doctor for a child with a serious allergy. Check your state’s rules, including its rules for giving medicine.

Find your state’s licensing page

More free forms

Questions, answered

Who fills in the allergy action plan?

The child’s doctor fills in the plan and signs it. A parent signs too, and staff follow it as written.

How do we keep a child with a food allergy safe at meals?

Give the cook a copy of every child’s food restrictions. Serve the foods listed under “Foods to give instead.”

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