Childcare Allergy and Special Diet Action Plan

Documents a child's food allergies, emergency response steps, approved substitutions, and caregiver instructions for use in food prep and classroom areas.

Child and Guardian Information

• Child's Full Name
• Child's Date of Birth
• Parent/Guardian Full Name
• Parent/Guardian Phone Number
• Parent/Guardian Email
• Classroom or Group

Allergy and Diet Details

• What best describes this plan?
• Allergens or Restricted Foods
• If you selected Other, describe the restricted food or ingredient
• Typical Reaction Severity
• Known Symptoms or Warning Signs
  List observable symptoms staff should watch for, such as hives, coughing, swelling, vomiting, or behavior changes.

Emergency Response Plan

• Emergency Steps for Staff
  Include what to do first, who to call, and when to activate emergency services.
• Is epinephrine authorized for this child?
• Medication Location
• Emergency Contact Name
• Emergency Contact Phone

Approved Substitutions and Food Handling

• Approved Food Substitutions
  List foods or brands that are safe alternatives for meals, snacks, and classroom treats.
• Cross-Contact Precautions
• If you selected Other, describe the precaution
• Foods to Avoid in Classroom Activities
  Include items used in crafts, celebrations, or sensory activities that should not be used around the child.

Consent and Acknowledgment

• I understand this form collects PII needed to support my child's care and may be shared with authorized staff on a need-to-know basis.
• I consent to this allergy and special diet action plan being posted or made available in food prep and classroom areas for safety purposes.
• I confirm the information provided is accurate and I will notify the childcare center of any changes immediately.
• Parent/Guardian Signature
• Date Signed