Date Registration Completed ________________

SPECIAL EVENT CHILD CARE REGISTRATION FORM To be completed, signed, and placed on file in the facility on the first day and updated as changes occur and at least annually

CHILD INFORMATION: Date of Birth: ____________________ Full Name:________________________________________________________________________________________________________

Last First Middle Nickname Child's Physical Address:__________________________________________________________________________________________________ FAMILY INFORMATION: Child lives with: ___________________________________________________ Father/Guardian’s Name ____________________________________________________ Home Phone ______________________ Address (if different from child’s) ____________________________________________________ Zip Code __________________ Work Phone __________________________________________________________ Cell Phone_________________________

Mother/Guardian’s Name ___________________________________________________ Home Phone ______________________ Address (if different from child’s) ____________________________________________________ Zip Code __________________ Work Phone __________________________________________________________ Cell Phone_________________________

CONTACTS: Child will be released only to the parents/guardians listed above. The child can also be released to the following individuals, as authorized by the person who signs this registration form. In the event of an emergency, if the parents/guardians cannot be reached, the facility has permission to contact the following individuals. _____________________________________________________________________________________________________ Name Relationship Address Phone Number _____________________________________________________________________________________________________ Name Relationship Address Phone Number _____________________________________________________________________________________________________ Name Relationship Address Phone Number

HEALTH CARE NEEDS: For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan must be completed and attached to this registration form. The medical action plan must be completed by the child’s parent or health care professional. Is there a medical action plan attached? Yes__ No__

List any allergies and the symptoms and type of response required for allergic reactions. _______________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________ List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns __________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List any particular fears or unique behavior characteristics the child has_____________________________________________________________ _____________________________________________________________________________________________________________________ List any types of medication taken for health care needs_________________________________________________________________________ Share any other information that has a direct bearing on assuring safe medical treatment for your child____________________________________ _____________________________________________________________________________________________________________________

I, as the parent/guardian, agree that the operator, YMCA of Western North Carolina, may authorize the physician of his/ her choice to provide emergency care in the event that neither I nor the family physician can be contacted immediately.I authorize for my child to be transported in the case of an emergency when medical attention by a physician is necessary. I understand that the YMCA staff is never to transport children in their personal vehicles at any time and a hospital or fire/emergency department will always be contacted.My child has permission to participate in all YMCA of Western North Carolina youth activities, including field trips and transportation where applicable. I grant permission for photographs, or other media, which include my child, quotes and written work to be used in media releases which benefit the YMCA. The Y does not administer over-the-counter medications to children. Y staff will administer prescription medications in their original container with the child’s name, accompanied by the appropriate medical action plan.I understand and agree to abide by the attached policies and procedures for Special Event Child Care.Accordingly, neither the YMCA nor any of its agents, employees, servants, community partners or invitees shall be liable to me or any of my family, agents, employees, servants, or invitees for any damage to persons or property when and to the extent that any such damage or injury may be caused, either proximately or remotely, wholly or in part, by any act or omission, whether negligent or not, of the YMCA or any of its agents, servants, community partners or invitees or due to the condition or design or any defect in the building, its mechanical systems, or its equipment.

Signature of Parent/Guardian_______________________________________________________________Date_______________

Special Event Child Care Policies Attendance, Drop-Off, and Pick-Up Policies For Special Event Child Care, be prepared to take additional time during drop-off to complete or

correct necessary paperwork.

An authorized adult must sign children in and out of program. Failure to sign your child(ren) in and

out may result in their removal from the program. Before the child(ren) can leave the YMCA area, the adult must sign them out and provide picture identification.

Only those people listed on the registration form will be allowed to pick up the child(ren). Additions

to the list can be made at any time by the parent(s)/guardian(s) listed on the registration. \ID is

required at pick-up time. This policy is for the safety of your child(ren).

Program Operating Hours/Dates Child care will be provided for this Special Event on November 16th, 2019 from 8:30 AM to 5:00

PM.

Growing Leaders Behavior Management Policy Y staff will use positive behavior management techniques that are developmentally appropriate and

that adhere to the Y’s four core values of caring, honesty, respect, and responsibility.

It is important that staff maintain good order, high expectations, and appropriate discipline in all programming. Top objectives in all YMCA programs are safety and a positive atmosphere for

learning and developing social skills. The YMCA makes every effort to help campers understand

clear definitions of acceptable and unacceptable behavior. All children must be able to follow behavior expectations and participate in all program activities.

Parents/guardians are required to inform the YMCA program staff in writing of any special

circumstances that may affect the youth’s ability to participate fully and to stay within the

guidelines of acceptable behavior, including any behavioral problems and psychological, medical, or physical conditions. YMCA staff are not responsible for providing a one-on-one counselor.

Expectations for Children Children are expected to:

• Participate in age-appropriate group

activities

• Cooperate with staff and follow

directions

• Respect other students and staff,

equipment, facilities, and themselves

• Maintain a positive attitude

• Stay in program areas and with

designated group

• Use appropriate language

Behavior Management Techniques Y staff will:

• Involve the children in the

development of the “house rules”

• Maintain consistent behavior

expectations and reinforce the Y’s

four core values

• Guide children by setting clear,

consistent, and fair limits for program

behavior

• Use natural and logical consequences

• Redirect children to more acceptable

behavior or an activity

• Use positive reinforcement, including

a positive behavior recognition

program

• Make eye contact and listen when

children talk about their feelings and

frustrations

• Guide children to resolve their own

conflicts through the use of conflict

resolution skills

• Use effective praise that is

immediate, sincere, and specific

• Modify and structure the environment

to attempt to prevent problems before they occur

Behavior Management Action Steps Y staff will work with children and families in the following ways:

1. If the youth is unable to comply with the behavior expectations, staff will give one warning

and attempt to redirect behavior by giving the child positive choices. Staff will never use

any form of corporal punishment.

2. If after the first warning the youth is still unable to comply with the behavior expectations, staff will use logical consequences and positive discipline to develop a behavioral plan with

the child.

3. If, after these interventions, the child is unable to comply with the YMCA behavior

expectations, staff will call parents/guardians. They will be required to pick up the camper early from program and sign a write-up form.

4. If the youth’s behavior continues to be disruptive and/or unsafe, the youth will be subject

to suspension or dismissal.

All suspensions require a meeting with the program director. At this meeting a behavior contract

will be established and signed by the child, parent, and staff before the child may return to the program.

Three behavior write-ups in any single semester or summer may result in suspension.

Certain behaviors will result in an immediate parent call, suspension, or removal from the program:

• Any actions that threaten the physical/emotional safety of the child, other youth, or staff

• Possession of a weapon of any kind

• Vandalism, destruction, or theft of YMCA or schools’ property

• Sexual misconduct

• Running away from designated group area

• Parent refusal to sign a discipline write-up form.

The parent/guardian is responsible for contacting the youth development director to set up an

appointment to discuss the child’s behavior before the child can return to the program.

Suspension Serious behavior problems will result in immediate suspension from the program. If the child is

reinstated and then receives a fourth behavior write-up, the child will be suspended immediately. If

necessary, the parent will be notified to pick up the child immediately. Upon the fourth report, the child will be removed from the program without the right of reinstatement during the program year.

Removal Y summer day camp programs cannot serve children who display chronically disruptive behavior.

Chronically disruptive behavior is defined as verbal or physical activity that may include, but is not

limited to:

• behavior that requires constant attention from the staff

• behavior that inflicts physical or emotional harm on other children or self

• behavior that is abusive toward the staff and/or shows that a camper is ignoring or

disobeying the rules

If a child cannot adjust to the program and behave appropriately, the child may not be able to

remain enrolled.

Reasonable efforts will be made to assist children in adjusting to the program setting.

Children with Special Needs The YMCA of Western North Carolina operates within the provisions of all applicable laws, including

those that provide protection to individuals with disabilities as well as to providers who care for

such individuals. Y programs welcome all children to the extent they are reasonably able to do so. A child who requires measures that constitute a fundamental alteration to the program or other

undue hardship, or a child who poses a direct threat to the health and safety of others, will not be

able to participate in the program.

Before a child’s admittance to the program, it is imperative that a YMCA youth development director make an individualized assessment as to whether the program meets the particular needs

of the child within the noted guidelines. Upon receiving the child’s registration form, our staff will

be in contact with the parents/guardians for a preliminary intake interview to gather all necessary and pertinent information to serve the participant to the best of our abilities within the parameters

of the program design.

If Y staff and/or the parents or guardians feel it necessary, a meeting will be scheduled for the Y

staff and the parents/guardians to discuss the situation.

Upon your child’s enrollment in the program, the youth development director will review the Individualized Care Plan (ICP) within two business days and schedule a parent consultation, if

needed, so the staff understands the best ways to provide care for your child. The ICP will also

note any special accommodations that are necessary to ensure the child’s success in the program.

This information will be shared with site staff, and follow-up calls and/or meetings with program coordinators will be arranged on an as-needed basis.

Health and Safety Medication Policy The Y does not administer over-the-counter medications to children. Y staff will administer

prescription medications in their original container with the child’s name, accompanied by a

Medication Release Authorization form that has been completed and signed by a parent/guardian and includes the following information:

• Child’s name

• Type of medication

• Physician’s name

• Instructions on amount of dosage (must match instructions on container)

• Time to be given (cannot write “as needed”)

• Number of days to be administered (up to six months for ongoing medications)

• Possible side effects

Please note that Y staff are NOT allowed to give the first dosage of any medication. If a child refuses medication, the incident will be documented and discussed with the child’s parent/guardian.

All medication on site is to be checked in with the site director on duty so it can be properly locked

for the safety of the children.

Insulin/Inhalers/EpiPens Children are not allowed to keep insulin, inhalers, or EpiPens in their backpacks or with them while attending the program.

Should your child require insulin, an inhaler, or an EpiPen, Y staff will keep that medication on their

person at all times. The same medication authorization release is required.

Such medications are to be given directly to the site director. We recognize the need for immediate access and therefore do not keep these medications locked as we do with all other forms of medication.

If a child needs his/her EpiPen, the child will insert the EpiPen and Y staff will contact 911 and the

child’s parent/guardian immediately.

Sunscreen and Hand Sanitizer If you choose to send sunscreen, it must be noted on your child’s registration form and be labeled

appropriately in a zip-top bag with child’s name and date, and the appropriate over-the-counter

medication authorization. All sunscreen is kept out of reach of children.

Sick or Ill Children To ensure the well-being of all children, please be considerate. If your child is too sick to go outside, he/she is too sick to attend child care.

Any child showing or developing symptoms such as fever, rash, diarrhea, or vomiting will be sent

home. Y staff will contact parents/guardians for immediate pick up.

Contagious Illnesses/Conditions If a child has a confirmed case of a contagious illness/condition, he/she must be kept at home and the condition reported to the site director. If a child exhibits symptoms of any contagious

illness/condition, Y staff will contact the parent/guardian and require them to pick up their child immediately. At the discretion of the site director, parents/guardians may be asked to submit a

doctor’s statement before the child returns to the site.

Examples of contagious illnesses and conditions include:

• Strep throat

• Chicken pox

• Hand, foot, and mouth disease

• Impetigo

• Lice

Emergency Medical Care The health and safety of the children in our care is our top priority. Even so, young children are often testing their physical limits, making injuries inevitable. Y staff will verbally inform parents/ guardians of any injuries. Y staff will call parents/ guardians if a child sustains a head injury.

In the event of a medical emergency or accident requiring a doctor’s treatment, we will contact parents/guardians immediately, and emergency personnel if necessary.

The YMCA of Western North Carolina may authorize the physician of its choice to provide emergency care in the event that a parent/guardian cannot be contacted immediately.

Parents/guardians authorize their child to be transported in the case of an emergency when medical

attention by a physician is necessary. Y staff will not transport children in their personal vehicles at any time and will always contact a hospital or fire/emergency department.

We, as the operator, YMCA of Western North Carolina, do agree to secure transportation to an

appropriate medical resource in the event of an emergency. In an emergency situation, other

children in the facility will be supervised by a responsible adult. Provisions will be made for adequate and appropriate rest and outdoor play.

Signature of Operator/YMCA Representative:

Paul Vest President and CEO

YMCA of Western North Carolina

Staff Relationships with Children Outside YMCA Programs Staff may not be alone with children they meet at the YMCA or in YMCA programs. This includes all forms of communication (phone calls, emails, instant messages, text messages, etc.).

Babysitting, hosting or attending sleepovers, and inviting staff members to a child’s home are

prohibited unless one of the following conditions exists:

• Staff and child’s family have a relationship that predates the staff member’s employment or

volunteering with the Y.

• Staff and the child’s family have a relationship that predates the child’s enrollment in the Y

program.

• Staff and the child or child’s family are related.

If you have an existing relationship with a Y staffer, you must contact Melissa Wiedeman at

mwiedman@ymcawnc.org or 828 210 2278 to complete appropriate disclosures and

documentation.

The Y recognizes there are occasions when children ask a staff member to attend their sporting event, dance recital, etc. This is permitted only if it is a public event and the child and staff member

are never alone together. YMCA staff are NEVER allowed to transport children in their personal

vehicles.

Tobacco Policy The use of any product containing, made of, or derived from tobacco, including, but not limited to,

ecigarettes, cigars, little cigars, smokeless tobacco, and hookahs, is not permitted on the premises

of the child care program, on vehicles used to transport children, or during any off-premises activities.

Intoxicated Adult Policy Y staff will encourage any adult who appears intoxicated to call an emergency contact or another adult authorized to pick up the child or request a taxi to transport the adult and child home safely.

Parents who arrive at the Y who appear to be intoxicated will be encouraged to stay with us and

relax. If an adult chooses to leave, Y staff will call the police.

Custody Issues In the event of a difficult/dangerous custody situation where a court order is in place, please

contact Will Deter, wdeter@ymcawnc.org, to set up guidelines regarding the release of your child.

You must have a copy of any court documents regarding the restriction of release of children in our care.

Parents/guardians are responsible for resolving any issues that may arise from their child’s

participation in our programs. The Y will not get involved in disputes. A child may be removed from

the program until the parents/guardians are able to resolve the differences.

Reporting Child Abuse North Carolina law requires any person who suspects child abuse or neglect to report the case to

the county Department of Social Services. Y staff will report all suspicions of child abuse or neglect.

How to Report a Problem Open communication is vital. We are here to address and work through problems and concerns. We encourage you to report all problems and concerns to your child’s site director. You can also direct

problems and concerns to:

Melissa Wiedeman, Vice President of Operations, K-12 Child Care YMCA of Western North Carolina

828 210 2278 or mwiedeman@ymcawnc.org

Medication Administration Permission 10A NCAC 09 .0803 (centers) and .1720(b) (family child care homes)

Parent/guardian completes the Medication Administration Permission and must sign and date it. The person accepting this form must attach the Medication Administration Record(s) to this form. Permission valid from date: To date:

Only complete this box if the medication is for a child who has a chronic medical condition or an allergy ☐ This document is written permission to administer this medication for up to 6 months. Specific chronic medical or allergic condition: Child has an ☐ Action Plan ☐ Individualized Health Care Plan Child’s full name: Date of birth: Medication Name: Expiration Date: Date(s) to give medication:

When to give medication (choose one): Give medication at these specific times (list times):

Give medication as-needed (write as-needed criteria below): List the specific symptoms or circumstances needed to give the medication and how often it can be given. For example: If Suzy has a rash and is scratching it, apply this ointment to the rash. Wait at least 6 hours before reapplying.

Dosage (how much medication to give): Route (how to give the medication): Special instructions on how to give medication: Possible Reactions or side effects: ☐ Child has received at least one dose of medication at home without reactions or side effects. Prescribing health care professional name: Phone: Pharmacy Phone: I give authorization to give medicine and to call the prescribing health care professional or pharmacy if needed

Parent/guardian name: Parent/guardian signature: Date: Medication received, returned, or disposed of:

Received from Parent/ Guardian

Date Amount Parent/Guardian Signature Child Care Provider Signature

Returned to Parent/Guardian

Date Amount Child Care Provider Signature Witness Signature

Disposed of Medicine Date Amount Child Care Provider Signature Witness Signature

Medication Administration Record 10A NCAC 09 .0803 (centers) and .1720 (family child care homes)

NC Child Care Health and Safety Resource Center and NC DHHS DCDEE Updated November 2017

Person who gives the child the medicine completes this Medication Administration Record. Copy this page when you need more lines to record medication administration. Attach page to the Medication Administration Permission.

If an error occurs and the child requires medical attention, call 9-1-1 and/or Poison Control immediately. Child’s name:

Medication name: Date given

Time given

Dose given

Route Name of person giving medication

Signature of person giving medication

Reaction/side effect, if observed

Date Time Error or mishap while giving medication Parent/guardian notified?

Child care provider signature

Yes No

Yes No

Yes No

Allergy and Anaphylaxis Emergency Plan

Child’s name: _________________________________ Date of plan: ________________

Date of birth: ____/____/______ Age _____ Weight: _________kg

Child has allergy to _________________________________________________________ Child has asthma. Yes No (If yes, higher chance severe reaction) Child has had anaphylaxis. Yes No Child may carry medicine. Yes No Child may give him/herself medicine. Yes No (If child refuses/is unable to self-treat, an adult must give medicine) IMPORTANT REMINDER Anaphylaxis is a potentially life-threating, severe allergic reaction. If in doubt, give epinephrine. For Severe Allergy and Anaphylaxis What to look for If child has ANY of these severe symptoms after eating the food or having a sting, give epinephrine. Shortness of breath, wheezing, or coughing Skin color is pale or has a bluish color Weak pulse Fainting or dizziness Tight or hoarse throat Trouble breathing or swallowing Swelling of lips or tongue that bother breathing Vomiting or diarrhea (if severe or combined with other

symptoms) Many hives or redness over body Feeling of “doom,” confusion, altered consciousness, or

agitation

Give epinephrine! What to do 1. Inject epinephrine right away! Note time when

epinephrine was given. 2. Call 911.

Ask for ambulance with epinephrine.

Tell rescue squad when epinephrine was given. 3. Stay with child and:

Call parents and child’s doctor.

Give a second dose of epinephrine, if symptoms get worse, continue, or do not get better in 5 minutes.

Keep child lying on back. If the child vomits or has trouble breathing, keep child lying on his or her side.

4. Give other medicine, if prescribed. Do not use other medicine in place of epinephrine.

Antihistamine

Inhaler/bronchodilator

For Mild Allergic Reaction What to look for If child has had any mild symptoms, monitor child. Symptoms may include:

Itchy nose, sneezing, itchy mouth A few hives Mild stomach nausea or discomfort

Monitor child What to do Stay with child and: Watch child closely. Give antihistamine (if prescribed). Call parents and child’s doctor. If symptoms of severe allergy/anaphylaxis develop,

use epinephrine. (See “For Severe Allergy and Anaphylaxis.”)

Medicines/Doses Epinephrine, intramuscular (list type):__________________ Dose: 0.15 mg 0.30 mg (weight more than 25 kg) Antihistamine, by mouth (type and dose): ______________________________________________________________ Other (for example, inhaler/bronchodilator if child has asthma): _____________________________________________ ________________________________ ______________ _______________________________ _____________ Parent/Guardian Authorization Signature Date Physician/HCP Authorization Signature Date

© 2017 American Academy of Pediatrics. All rights reserved. Your child’s doctor will tell you to do what’s best for your child. This information should not take the place of talking with your child’s doctor. Page 1 of 2.

Attach child’s photo

� SPECIAL SITUATION: If this box is checked, child has an extremely severe allergy to an insect sting or the following food(s):______________________. Even if child has MILD symptoms after a sting or eating these foods, give epinephrine.

Allergy and Anaphylaxis Emergency Plan Child’s name: ________________________________________ Date of plan: ________________________________

Additional Instructions:

Contacts

Call 911 / Rescue squad: (___) _____-_________

Doctor: ___________________________________________________________ Phone: ( ) - .

Parent/Guardian: ____________________________________________________ Phone: (_ __) _____-_________

Parent/Guardian: ____________________________________________________ Phone: (_ __) _____-_________

Other Emergency Contacts

Name/Relationship: __________________________________________________ Phone: (__ _) _____-_________

Name/Relationship: __________________________________________________ Phone: (_ __) _____-_________

© 2017 American Academy of Pediatrics. All rights reserved. Your child’s doctor will tell you to do what’s best for your child. This information should not take the place of talking with your child’s doctor. Page 2 of 2.

1 Medical Action Plan - Asthma

10A NCAC 09 .0801 (centers) and .1721 (family child care homes)

NC Child Care Health Consultants Association, the NC Child Care Health and Safety Resource Center, and NC DHHS DCDEE Updated November 2017

Action plan’s must be completed by the child's parent or health care professional, attached to the child’s application, and updated annually. The completed action plan should be stored in the child’s file and facility’s Ready to Go File and a copy kept in the classroom. Name of person completing form: Today’s date: Child's full name: Date of birth: Parent/guardian: Phone: Primary Health Care Professional name: Phone: Primary Health Care Professional signature:

Asthma Triggers (Avoid exposure to triggers) Severity of asthma □ Carpet □ Animals □ Tobacco smoke

□ Mold □ Pollen □ Dust (mites)

□ Cockroaches □ Chemical sprays □ Strong odors

□ Changes in weather □ Illness □ Other:__________________

□ Mild intermittent □ Mild persistent □ Moderate persistent □ Severe persistent

List Allergies: Consult with a Child Care Health Consultant about this plan.

GREEN - GO Child is breathing well. Use these long-term CONTROL medicines every day to keep child in the green zone.

No cough or wheeze.

Sleeps well at night.

Plays actively.

No early warning

signs.

Medicine: How much to give: When to give: __________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Medication before active play or exercise: □ None needed □ Medication _______________ Give _____ minutes before active play or exercise.

YELLOW – CAUTION Child has some problems breathing.

Keep using long-term CONTROL green zone medicines every day. Add quick-relief medicines to keep asthma from becoming worse. Parent/legal guardian contacts the Health Care Professional when quick-relief medicine is used more than twice in a week.

Coughing Wheezing May squat or

hunch over Chest tight

Waking often Poor appetite Decreased play or activity

Other early symptoms (child specific): ______________ ______________ ______________

At Home Medicine: How much to give: When to give: Albuterol _______ OR ____________

___ 2 puffs by inhaler (with spacer) ___ by nebulizer (with mask)

Give first dose as soon as possible. Repeat every ____ minutes for up to a total of ____ doses if needed.

If symptoms return to Green Zone:

If symptoms do not return to Green Zone within 1-2 hours:

• Take quick-relief medicine every 4 hours for ___ days.

• Change long-term control medicines to _____________________ for ___ days.

• Contact Health Care Professional for follow-up care if symptoms return.

Take quick-relief medication again. Contact Health Care Professional.

At Child Care Medicine: How much to give: When to give: Albuterol _______ OR ____________

___ 2 puffs by inhaler (with spacer) ___ by nebulizer (with mask)

Give first dose as soon as possible. Call parent/guardian if symptoms do not return to green zone within 15 minutes. Repeat every _____ minutes for up to a total of _____ doses if needed.

If symptoms return to Green Zone:

If symptoms do not return to Green Zone within 1 hour:

Continue quick-relief medicine every 4 hours for remainder of time in care.

Have parent/guardian pick child up and care for the child.

See page 2 for RED – DANGER: Child has severe problems with breathing.

2 Medical Action Plan - Asthma

10A NCAC 09 .0801 (centers) and .1721 (family child care homes)

NC Child Care Health Consultants Association, the NC Child Care Health and Safety Resource Center, and NC DHHS DCDEE Updated November 2017

RED – DANGER Child has severe problems with breathing.

Get help! Give quick-relief medicines until help arrives.

Severe Symptoms Getting worse

instead of better. Coughing

constantly. Cannot talk well. Cannot play or

walk. Breathing is

hard and fast, gasping. Nostrils open

wide when child breathes. Chest muscles

tight. Space between the ribs and over the chest bone suck in with each breath. Fingernails or

lips blue.

CHILD HAS SEVERE SYMPTOMS!

At Home Medicine: How much to give: When to give: Albuterol ________ OR _____________

___ 2 puffs by inhaler (with spacer) ___ by nebulizer (with mask)

• Give a dose immediately and call

Health Care Professional. • Repeat every ____ minutes until

medical help is obtained. • Do not leave child alone.

CALL 9-1-1 if symptoms last more than a few minutes.

At Child Care Medicine: How much to give: When to give:

Albuterol ________ OR _____________

___ 2 puffs by inhaler (with spacer) ___ by nebulizer (with mask)

• Give a dose immediately. • Call parent/guardian if not

previously called. • Call Health Care Professional if

unable to reach parent/guardian. • Repeat dose every ______ minutes

until medical help is available. • Do not leave child alone.

Plan reviewed by: Child Care Director/Operator name: Date:

Signature:

Child Care Health Consultant name: Date:

Signature:

Child care staff trained to care for child: #1: #2: #3:

Who will move and/or care for other children?

Who will notify the child’s parents?

Who will call and assist EMS (911) when needed?

Who will go to the hospital when needed and stay with child until parent/legal guardian assumes responsibility?

Child Care DiabetesMedical Management PlanName of Child: ________________________________________ DOB: __________ Dates Plan in Effect: ______________

Parent or guardian Name(s)/Number(s): _____________________________________________________________________

Diabetes Care Provider Name/Number: ______________________________________________________________________

Diabetes Care Provider Signature: _______________________________________________________ Date: ______________

Location of diabetes supplies at child care facility: _____________________________________________________________

Blood Glucose MonitoringTarget range for blood glucose is: � 80-180 � Other ________________________________________________________

When to check blood glucose: � before breakfast � before lunch � before dinner � before snacks

When to do extra blood glucose checks: � before exercise � after exercise � when showing signs of low blood glucose

� � when showing signs of high blood glucose � other ______________________

Insulin Plan: Please indicate which type of insulin regimen this child uses (check one):

� � Insulin Pump � Multiple Daily Injections � Fixed Insulin Doses

Specific information related to each insulin regimen/plan is included below for this child.

Type of insulin used at child care (check all that apply): � Regular � Apidra � Humalog � Novolog � NPH

� Lantus � Levemir � Mix � Other ______________

Plan A: Insulin Pump*1. Always use the insulin pump bolus

wizard: � Yes � No

If no, use Insulin:Carbohydrate Ratio and

Correction Factor dosage on Plan B.

2. Blood glucose must be checked before

the child eats and will (check one):

�� Be sent to the pump by the meter

�� Need to be entered into the pump

3. The insulin pump will calculate the

correction dose to be delivered before

the meal/snack.

4. After the meal/snack, enter the total

number of carbohydrates eaten at

that meal/snack. The insulin pump will

calculate the insulin dose for the meal.

5. Contact parent/guardian with any

concerns.

For a list of definitions of terms used in

this document, please see the Diabetes

Dictionary.

*Providers should complete Insulin:Carbohydrate ratio and Correction dosage under Plan B section for ALL pump users.

Plan B: Multiple Daily Injections1. Child will receive a fixed dose of

__________ long-acting insulin at

__________ � Yes � No

2. Follow blood glucose monitoring

plan above.

3. Use _____________ insulin for meals and snacks. Insulin dose for food is

_____ unit(s) for meals OR _____ unit(s) for every _____ grams

carbohydrate.

Give injection after the child eats.

4. If blood glucose is above target, add

correction dose to:

�� Breakfast � Snack � Lunch � Snack � Other: _____________________

Use the following correction factor

_____________ or this scale:

_____ units if BG is _____ to _____

_____ units if BG is _____ to _____

_____ units if BG is _____ to _____

_____ units if BG is _____ to _____

Only add correction dose if it has been 3 hours since the last insulin administration.

C: Fixed Insulin Doses1. Child will receive a fixed dose of long

acting insulin? � Yes � No If yes, give child _________ units of

_________ insulin at _________.

2. Insulin correction dose at child care

( _________ insulin)?

� Yes � No

3. If blood glucose is above target, add

correction dose to:

�� Breakfast � Snack � Lunch � Snack � Other: _____________________

Use the following correction factor

_____________ or the following

scale:

_____ units if BG is _____ to _____

_____ units if BG is _____ to _____

_____ units if BG is _____ to _____

_____ units if BG is _____ to _____

Only add correction dose if it has been 3 hours since the last insulin administration.

Managing Very Low Blood GlucoseHypoglycemia Plan for Blood Glucose less than ______________ mg/dL1. Give 15 grams of fast acting carbohydrate.2. Recheck blood glucose in 15 minutes.3. If still below 70 mg/dL, offer 15 grams of fast acting

carbohydrate, check again in 15 minutes.4. When the child’s blood glucose is over 70, provide 15g of

carbohydrate as snack. Do not give insulin with this snack.5. Contact the parent/guardian any time blood glucose is

less than ________ mg/dL at child care.

Usual symptoms of hypoglycemia for this child include:� Shaky � Fast heartbeat � Sweating� Anxious � Hungry � Weakness/Fatigue� Headache � Blurry vision � Irritable/Grouchy� Dizzy � Other __________________________

1. If you suspect low blood glucose, check blood glucose!2. If blood glucose is below ________, follow the plan above.3. If the child is unconscious, having a seizure (convulsion) or

unable to swallow:

the first hash mark on the syringe. Then inject into the thigh. Turn child on side as vomiting may occur.

911 (or other emergency assistance). After calling 911, contact the parents/guardian. If unable to reach parent, contact diabetes care provider.

Managing Very High Blood GlucoseHyperglycemia Plan for Blood Glucose higher than ______________ mg/dLUsual symptoms of hyperglycemia for this child include:� Extreme thirst � Very wet diapers, accidents� Hungry � Warm, dry, flushed skin � Tired or drowsy � Headache � Blurry vision � Vomiting**� Fruity breath � Rapid, shallow breathing � Abdominal pain � Unsteady walk (more than typical)**If child is vomiting, contact parents immediately

Treatment of hyperglycemia/very high blood glucose: 1. Check for ketones in the: � urine � blood (parent will provide training) 2. If ketones are moderate or large, contact parent. If

unable to reach parent, contact diabetes care provider for additional instructions.

Contact parent if ketones are trace or small: � Yes � No

insulin if the last dose of insulin was given 3 or more hours earlier. Consult the insulin plan above for instructions. If still uncertain how to manage high blood glucose, contact the parent.

4. Provide sugar free fluids as tolerated.5. You may also:�� Provide carbohydrate free snacks if hungry�� Delay exercise��

to the bathroom�� Stay with the child

Diabetes DictionaryBlood glucose - The main sugar found in the blood and the body’s main source of energy. Also called blood sugar. The blood glucose level is the amount of glucose in a given amount of blood. It is noted in milligrams in a deciliter, or mg/dL.Bolus - An extra amount of insulin taken to lower the blood glucose or cover a meal or snack.Bolus calculator – A feature of the insulin pump that uses input from a pump user to calculate the insulin dose. The user inputs the blood glucose and amount of carbohydrate to be consumed, and the pump calculates the dose that can be approved by the user. Correction Factor – The drop in blood glucose level, measured in milligrams per deciliter (mg/dl), caused by each unit of insulin taken. Also called insulin sensitivity factor. Diabetic Ketoacidosis (DKA) – An emergency condition caused by a severe lack of insulin, that results in the breakdown of body fat for energy and an accumulation of ketones in the blood and urine. Signs of DKA are nausea and vomiting, stomach pain, fruity breath odor and rapid breathing. Untreated DKA can lead to coma and death.Fixed dose regimen – Children with diabetes who use a fixed dose regimen take the same “fixed” doses of insulin at specific times each day. They may also take additional insulin to correct hyperglycemia. Glucagon – A hormone produced in the pancreas that raises blood glucose. An injectable form of glucagon, available by prescription, is used to treat severe hypoglycemia or severely low blood glucose.Hyperglycemia - Excessive blood glucose, greater than 240 mg/dL for children using and insulin pump and greater than 300 mg/dL for children on insulin injections. If untreated, the patient is at risk for diabetic ketoacidosis (DKA).Hypoglycemia - A condition that occurs when the blood glucose is lower than normal, usually less than 70 mg/dL. Signs include hunger, nervousness, shakiness, perspiration, dizziness or light-headedness, sleepiness, and confusion. If left untreated, hypoglycemia may lead to unconsciousness. Insulin - A hormone that helps the body use glucose for energy. The beta cells of the pancreas make insulin. When the body cannot make enough insulin, it is taken by injection or through use of an insulin pump.Insulin Pump - An insulin-delivering device about the size of a deck of cards that can be worn on a belt or kept in a pocket. An insulin pump connects to narrow, flexible plastic tubing that ends with a needle inserted just under the skin. Pump users program the pump to give a steady trickle or constant (basal) amount of insulin continuously throughout the day. Then, users set the pump to release bolus doses of insulin at meals and at times when blood glucose is expected to be higher. This is based on programming done by the user.

Ketones - A chemical produced when there is a shortage of insulin in the blood and the body breaks down body fat for energy. High levels of ketones can lead to diabetic ketoacidosis and coma. Multiple Daily Injection Regimen - Multiple daily insulin regimens typically include a basal, or long acting, insulin given once per day. A short acting insulin is given by injection with meals and to correct hyperglycemia, or elevated blood glucose, multiple times each day.Type 1 Diabetes - Occurs when the body’s immune system attacks the insulin-producing beta cells in the pancreas and destroys them. The pancreas then produces little or no insulin. Type 1 diabetes develops most often in young people but can appear in adults. It is one of the most common chronic diseases diagnosed in childhood.

_____________________________________________________________________Physician Signature

Nombre ____________________________________________________________Fecha de nacimiento: ____________________

Alérgico a: _________________________________________________________________________________________________

Peso: __________________ kilos. Asma: [ ] Sí (Riesgo más alto de reacción grave) [ ] No

COLOQUE UNA

FOTOGRAFÍA AQUÍ

1. Se pueden administrar antihistamínicos, con prescripción médica.

2. Quédese junto a la persona; comuníquese con los contactos de emergencia.

3. Observe atentamente los posibles cambios. Si los síntomas empeoran, administre epinefrina.

FIRMA DE AUTORIZACIÓN DEL PACIENTE O PADRE/TUTOR FECHA FIRMA DE AUTORIZACIÓN DEL MÉDICO O PROFESIONAL DE SALUD INTERVINIENTE FECHA

FORMULARIO SUMINISTRADO POR CORTESÍA DE FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 3/2017

1. INYECTE EPINEFRINA DE INMEDIATO2. Llame al 911. Avise al operador telefónico que el paciente tiene anafilaxia

y puede necesitar epinefrina cuando llegue el equipo de emergencia.• Considerelaadministracióndeotrosmedicamentosademásdela

epinefrina: -Antihistamínico -Inhalador (broncodilatador) en caso de respiración sibilante• Mantenga al paciente en posición horizontal, con las piernas

en alto y abrigado. Si tiene dificultades para respirar o vómitos, manténgalo sentado o tendido sobre un costado.

• Si los síntomas no mejoran o vuelven a aparecer, puede administrar otras dosis adicionales de epinefrina a partir de los 5 minutos de la administración de la última dosis.

• Comuníquese con los contactos de emergencia.• Lleve al paciente a la sala de emergencias, aunque los síntomas

hayan desaparecido. (El paciente debe permanecer en la guardia médica durante por lo menos 4 horas porque los síntomas pueden reaparecer).

CORAZÓN Tez azulada o

pálida,desmayo,pulso débil,

mareo

BOCA Hinchazón

significativa de la lengua o los

labios

O UNA COMBINACIÓN de los síntomas de las distintas

áreas

PULMÓN Falta de aire,

sibilancia,mucha tos

PIEL Urticaria

extendida en las distintas partes

del cuerpo, enrojecimiento generalizado

INTESTINOS Vómitos

reiterados,diarrea grave

NARIZ Picazón o

moqueo nasal, estornudos

BOCA Picazón bucal

PIEL Algunasronchas,

picazón leve

INTESTINO Náuseasleveso

malestarGARGANTA

Ronquera u oclusión,

dificultad para tragar o respirar

OTRO Sensación de que

va a pasar algo malo, ansiedad,

confusión.

Marcadeepinefrinaofármacogenérico: ________________________

Dosis de epinefrina: [ ] 0,15 mg IM [ ] 0,3 mg IM

Marcadeantihistamínicoofármacogenérico: ____________________

Dosis de antihistamínico: _____________________________________

Otros (por ejemplo, broncodilatador en caso de sibilancia): ________

____________________________________________________________

MEDICAMENTOS/DOSIS

SÍNTOMAS GRAVES SÍNTOMAS LEVES

EN CASO DE SÍNTOMAS LEVES EN MÁS DE UN ÁREA DEL CUERPO, ADMINISTRE EPINEFRINA.

EN CASO DE SÍNTOMAS LEVES EN UN ÁREA ÚNICA SIGA ESTAS INSTRUCCIONES:

ANTE CUALQUIERA DE LOS SIGUIENTES:

NOTA: No recurra a antihistamínicos ni inhaladores (broncodilatadores) para tratar una reacción grave. UTILICE EPINEFRINA.

Extremadamente reactivo a los siguientes alérgenos: ___________________________________________________

POR LO TANTO:[ ] Si esta opción está marcada y es PROBABLE que se ha ingerido el alérgeno, administre epinefrina de inmediato ante CUALQUIERA de estos síntomas.

[ ] Si esta opción está marcada y es SEGURO que se ha ingerido el alérgeno, administre epinefrina de inmediato aunque no se observe ningún síntoma.

PLAN DE ATENCIÓN DE EMERGENCIAS DE ALERGIAS ALIMENTARIAS Y ANAFILAXIA

CÓMO UTILIZAR LA INYECCIÓN DE EPINEFRINA IMPAX (GENÉRICO AUTORIZADO DE ADRENACLICK®), USP, AUTOINYECTOR, LABORATORIOS IMPAX 1. Retire del autoinyector de epinefrina de su estuche protector. 2. Saquelasdostapasdeextremoazul.Ahorapodráverunapuntaroja.3. Sujete el autoinyector firmemente con el puño con la punta roja apuntando hacia abajo. 4. Coloquelapuntarojacontralaparteexteriormediadelmusloenunángulode90º,enposiciónperpendicular

al muslo. 5. Oprima y sostenga con firmeza durante aproximadamente 10 segundos. 6. Retireeldispositivoymasajeeeláreadurante10segundos.7. Llameal911ypidaasistenciamédicadeemergenciadeinmediato.

CÓMO UTILIZAR LA INYECCIÓN DE EPINEFRINA (FÁRMACO GENÉRICO AUTORIZADO DE EPIPEN®), USP (AUTOINYECTOR), MYLAN 1. Retire el autoinyector de epinefrina del tubo transparente. 2. Sujete el autoinyector firmemente con el puño con la punta naranja (el extremo de la aguja) apuntando

hacia abajo.3. Con la otra mano, retire el protector de seguridad azul tirando firmemente hacia arriba. i4. Gire y oprima con firmeza el autoinyector contra la parte exterior media del muslo hasta que haga clic. 5. Sostenga firmemente en el lugar durante 3 segundos (cuente lentamente 1, 2, 3). 6. Retireeldispositivoymasajeeeláreadurante10segundos.7. Llameal911ypidaasistenciamédicadeemergenciadeinmediato.

CÓMO USAR EL AUTOINYECTOR DE EPINEFRINA EPIPEN® Y EPIPEN JR®, MYLAN1. Retire el autoinyector Epipen® o EpiPen Jr® del tubo transparente.2. Sujete el autoinyector firmemente con el puño con la punta naranja (el extremo de la aguja) apuntando

hacia abajo.3. Con la otra mano, retire el protector de seguridad azul tirando firmemente hacia arriba.4. Gire y oprima con firmeza el autoinyector contra la parte exterior media del muslo hasta que haga clic.5. Sostenga firmemente en el lugar durante 3 segundos (cuente lentamente 1, 2, 3).6. Retireeldispositivoymasajeeeláreadurante10segundos.

7. Llameal911ypidaasistenciamédicadeemergenciadeinmediato.

INSTRUCCIONES/INFORMACIÓN ADICIONAL (la persona puede llevar epinefrina, el paciente puede autoadministrarse la medicación, etc.):

FORMULARIO SUMINISTRADO POR CORTESÍA DE FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 3/2017

CONTACTOS DE EMERGENCIA – LLAME AL 911EQUIPO DE RESCATE: __________________________________________________________________

MÉDICO: _________________________________________________ TELÉFONO: ________________

PADRE O TUTOR: _________________________________________ TELÉFONO: ________________

OTROS CONTACTOS DE EMERGENCIA

NOMBRE/RELACIÓN: ___________________________________________________________________

TELÉFONO: ___________________________________________________________________________

NOMBRE/RELACIÓN: ___________________________________________________________________

TELÉFONO: ____________________________________________________________________________

Trate a la persona antes de llamar a los contactos de emergencia. Las primeras señales de una reacción pueden ser leves, pero los síntomas pueden agravarse con rapidez.

INFORMACIÓN DE ADMINISTRACIÓN Y SEGURIDAD PARA TODOS LOS AUTOINYECTORES:1. Nocoloqueeldedopulgar,losdemásdedosolamanosobrelapuntadelautoinyectorniapliquelainyecciónfueradelaparteexterior

mediadelmuslo.Encasodeinyecciónaccidental,diríjaseinmediatamentealasaladeemergenciasmáscercana.2. Si administra el medicamento a un niño pequeño, sostenga su pierna firmemente antes y durante la aplicación para evitar posibles

lesiones.3. Si es necesario, la epinefrina se puede aplicar a través de la ropa.

4. Llameal911inmediatamenteluegodeaplicarlainyección.

CÓMO UTILIZAR AUVI-Q® (INYECCIÓN DE EPINEFRINA, USP), KALEO1. Retire AUVI-Q del estuche externo.2. Saque la tapa de seguridad roja.3. Coloque el extremo negro de AUVI-Q® contra la parte exterior media del muslo.4. Oprima firmemente, y mantenga presionado durante 5 segundos.

5. Llameal911ypidaasistenciamédicadeemergenciadeinmediato.

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PLAN DE ATENCIÓN DE EMERGENCIAS DE ALERGIAS ALIMENTARIAS Y ANAFILAXIA

Name: _________________________________________________________________________ D.O.B.: ____________________

Allergy to: __________________________________________________________________________________________________

Weight: ________________ lbs. Asthma: [ ] Yes (higher risk for a severe reaction) [ ] No

PLACE PICTURE

HERE

1. Antihistamines may be given, if ordered by a healthcare provider.

2. Stay with the person; alert emergency contacts.

3. Watch closely for changes. If symptoms worsen, give epinephrine.

PATIENT OR PARENT/GUARDIAN AUTHORIZATION SIGNATURE DATE PHYSICIAN/HCP AUTHORIZATION SIGNATURE DATE

FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 4/2017

1. INJECT EPINEPHRINE IMMEDIATELY.2. Call 911. Tell emergency dispatcher the person is having

anaphylaxis and may need epinephrine when emergency responders arrive.

• Consider giving additional medications following epinephrine:

» Antihistamine » Inhaler (bronchodilator) if wheezing

• Lay the person flat, raise legs and keep warm. If breathing is difficult or they are vomiting, let them sit up or lie on their side.

• If symptoms do not improve, or symptoms return, more doses of epinephrine can be given about 5 minutes or more after the last dose.

• Alert emergency contacts.

• Transport patient to ER, even if symptoms resolve. Patient should remain in ER for at least 4 hours because symptoms may return.

HEART Pale or bluish

skin, faintness, weak pulse, dizziness

MOUTH Significant

swelling of the tongue or lips

OR A COMBINATION of symptoms from different body areas.

LUNG Shortness of

breath, wheezing, repetitive cough

SKIN Many hives over body, widespread

redness

GUT Repetitive

vomiting, severe diarrhea

NOSE Itchy or

runny nose, sneezing

MOUTH Itchy mouth

SKIN A few hives,

mild itch

GUT Mild

nausea or discomfort

THROAT Tight or hoarse throat, trouble breathing or swallowing

OTHER Feeling

something bad is about to happen, anxiety, confusion

Epinephrine Brand or Generic: ________________________________

Epinephrine Dose: [ ] 0.15 mg IM [ ] 0.3 mg IM

Antihistamine Brand or Generic: _______________________________

Antihistamine Dose: __________________________________________

Other (e.g., inhaler-bronchodilator if wheezing): __________________

____________________________________________________________

MEDICATIONS/DOSES

SEVERE SYMPTOMS MILD SYMPTOMS

FOR MILD SYMPTOMS FROM MORE THAN ONE SYSTEM AREA, GIVE EPINEPHRINE.

FOR MILD SYMPTOMS FROM A SINGLE SYSTEM AREA, FOLLOW THE DIRECTIONS BELOW:

FOR ANY OF THE FOLLOWING:

NOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. USE EPINEPHRINE.

Extremely reactive to the following allergens: _________________________________________________________

THEREFORE:[ ] If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms.

[ ] If checked, give epinephrine immediately if the allergen was DEFINITELY eaten, even if no symptoms are apparent.

HOW TO USE IMPAX EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF ADRENACLICK®), USP AUTO-INJECTOR, IMPAX LABORATORIES 1. Remove epinephrine auto-injector from its protective carrying case.2. Pull off both blue end caps: you will now see a red tip.3. Grasp the auto-injector in your fist with the red tip pointing downward.4. Put the red tip against the middle of the outer thigh at a 90-degree angle, perpendicular to the thigh.5. Press down hard and hold firmly against the thigh for approximately 10 seconds. 6. Remove and massage the area for 10 seconds.7. Call 911 and get emergency medical help right away.

HOW TO USE EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF EPIPEN®), USP AUTO-INJECTOR, MYLAN 1. Remove the epinephrine auto-injector from the clear carrier tube.2. Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. 3. With your other hand, remove the blue safety release by pulling straight up.4. Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’. 5. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).6. Remove and massage the injection area for 10 seconds.7. Call 911 and get emergency medical help right away.

HOW TO USE EPIPEN® AND EPIPEN JR® (EPINEPHRINE) AUTO-INJECTOR, MYLAN1. Remove the EpiPen® or EpiPen Jr® Auto-Injector from the clear carrier tube.2. Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. 3. With your other hand, remove the blue safety release by pulling straight up.4. Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’.5. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).6. Remove and massage the injection area for 10 seconds.7. Call 911 and get emergency medical help right away.

OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.):

FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 4/2017

EMERGENCY CONTACTS — CALL 911RESCUE SQUAD: ______________________________________________________________________

DOCTOR: _________________________________________________ PHONE: ____________________

PARENT/GUARDIAN: ______________________________________ PHONE: ____________________

OTHER EMERGENCY CONTACTS

NAME/RELATIONSHIP: __________________________________________________________________

PHONE: _______________________________________________________________________________

NAME/RELATIONSHIP: __________________________________________________________________

PHONE: _______________________________________________________________________________

Treat the person before calling emergency contacts. The first signs of a reaction can be mild, but symptoms can worsen quickly.

ADMINISTRATION AND SAFETY INFORMATION FOR ALL AUTO-INJECTORS:1. Do not put your thumb, fingers or hand over the tip of the auto-injector or inject into any body part other than mid-outer

thigh. In case of accidental injection, go immediately to the nearest emergency room.2. If administering to a young child, hold their leg firmly in place before and during injection to prevent injuries.3. Epinephrine can be injected through clothing if needed.4. Call 911 immediately after injection.

HOW TO USE AUVI-Q® (EPINEPHRINE INJECTION, USP), KALEO1. Remove Auvi-Q from the outer case.2. Pull off red safety guard.3. Place black end of Auvi-Q against the middle of the outer thigh.4. Press firmly, and hold in place for 5 seconds. 5. Call 911 and get emergency medical help right away.

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1 Child Medical Action Plan

The North Carolina Child Care Health and Safety Resource Center and NC DHHS DCDEE Updated November 2017

10A NCAC 09 .0801(b) [Centers] and .1721(a)(4) [Family Child Care Homes]

If a child has health care needs that require specialized health services, the child's parent or a health care professional should complete a medical action plan and attach it to the child’s application. The plan must be updated annually and stored in the child’s file and facility’s Ready to Go File. A copy should be kept in the classroom.

Children with asthma, diabetes, seizes, or allergies should have medical action plans specific to those conditions. Name of person completing form: Today’s date:

Child’s full name: Date of birth:

Parent’s/guardian’s name: Phone:

Primary health care professional: Phone:

Specialist/therapist: Type: Phone:

Specialist/therapist: Type: Phone:

Diagnosis(es):

Allergies (food, medication, environmental, insects, or other):

Medication(s) Complete a Medication Administration Permission Form if medications listed below are to be provided by the child care. Complete page three if child has more than two medications.

Medication name: Daily medication taken at child care

Daily medication taken at home

Emergency medication

Dosage: Time/frequency: Route:

Special instructions: Side effects: Reason prescribed:

Medication name: Daily medication taken at child care

Daily medication taken at home

Emergency medication

Dosage: Time/frequency: Route:

Special instructions: Side effects: Reason prescribed:

Accommodation(s) Describe any accommodation(s) the child needs in daily activities and why.

Diet or Feeding:

Classroom Activities:

Naptime/Sleeping:

Toileting:

Outdoors or Field Trips:

Transportation:

Other/Comments:

2 Child Medical Action Plan

The North Carolina Child Care Health and Safety Resource Center and NC DHHS DCDEE Updated November 2017

Equipment/Medical Supplies

Emergency Care

Suggested Special Training for Staff

If completed by a health care professional:

Parent notes

Parent/Guardian Signature: Date:

1.

2.

3.

4.

Call parents/guardians if the following symptoms are present:

Call 911 (emergency medical services) if the following symptoms are present, and contact the parents/guardians:

Take these measures while waiting for parents or medical help to arrive:

Health Care Professional Signature: Date:

3 Child Medical Action Plan

The North Carolina Child Care Health and Safety Resource Center and NC DHHS DCDEE Updated November 2017

Medication name: Daily medication

taken at child care Daily medication taken at home

Emergency medication

Dosage: Time/frequency: Route:

Special instructions: Side effects: Reason prescribed:

Medication name: Daily medication taken at child care

Daily medication taken at home

Emergency medication

Dosage: Time/frequency: Route:

Special instructions: Side effects: Reason prescribed:

Medication name: Daily medication taken at child care

Daily medication taken at home

Emergency medication

Dosage: Time/frequency: Route:

Special instructions: Side effects: Reason prescribed:

Medication name: Daily medication taken at child care

Daily medication taken at home

Emergency medication

Dosage: Time/frequency: Route:

Special instructions: Side effects: Reason prescribed:

Medication name: Daily medication taken at child care

Daily medication taken at home

Emergency medication

Dosage: Time/frequency: Route:

Special instructions: Side effects: Reason prescribed:

Medication name: Daily medication taken at child care

Daily medication taken at home

Emergency medication

Dosage: Time/frequency: Route:

Special instructions: Side effects: Reason prescribed:

Seizure Action Plan

Copyright 2014 Epilepsy Foundation of America, Inc. ®

This student is being treated for a seizure disorder. The information below should assist you if a seizure occurs during school hours.

Student’s Name Date of Birth

Parent/Guardian Phone Cell

Other Emergency Contact Phone Cell

Treating Physician Phone

Significant Medical History

Seizure Information

Seizure Type Length Frequency Description

Seizure triggers or warning signs: Students’s response after a seizure:

Basic First Aid Care & Comfort Basic Seizure First Aid

Please describe basic first aid procedures: • Stay calm & track time• Keep child safe• Do not restrain• Do not put anything in mouth• Stay with child until fully conscious• Record seizure in logFor tonic-clonic seizure:• Protect head• Keep airway open/watch breathing• Turn child on side

Does student need to leave the classroom after a seizure? p Yes p NoIf YES, describe process for returning student to classroom:

Emergency Response A seizure is generally considered an emergency when:• Convulsive (tonic-clonic) seizure lasts

longer than 5 minutes• Student has repeat seizures without

regaining consciousness• Student is injured or has diabetes• Student has a first-time seizure• Student has breathing difficulties• Student has a seizure in water

A “seizure emergency” for this student is defined as:

Seizure Emergency Protocol (Check all that apply and clarify below)p Contact school nurse at _________________________p Call 911 for transport to __________________________p Notify parent or emergency contactp Administer emergency medications as indicated belowp Notify doctorp Other________________________________________

Treatment Protocol During School Hours (include daily and emergency medications)

Emerg. Med. Medication Dosage & Time of Day Given Common Side Effects & Special Instructions

Does student have a Vagus Nerve Stimulator? p Yes p No If YES, describe magnet use:

Special Considerations and Precautions (regarding school activities, sports, trips, etc.)

Describe any special considerations or precautions:

Physician Signature_____________________________________________________________ Date___________________

Parent/Guardian/Signature________________________________________________________ Date___________________