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Run: Childcare Allergy and Special Diet Action Plan

A childcare allergy and special diet action plan for documenting a child’s food restrictions, emergency steps, approved substitutions, and caregiver instruct...

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Child and Guardian Information

Child's Full Name (required)

Child's Date of Birth (required)

Parent/Guardian Full Name (required)

Parent/Guardian Phone Number (required)

Parent/Guardian Email

Classroom or Group

Allergy and Diet Details

What best describes this plan? (required)

Allergens or Restricted Foods (required)

If you selected Other, describe the restricted food or ingredient

Typical Reaction Severity (required)

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 (required)

Include what to do first, who to call, and when to activate emergency services.

Is epinephrine authorized for this child? (required)

Medication Location

Emergency Contact Name (required)

Emergency Contact Phone (required)

Approved Substitutions and Food Handling

Approved Food Substitutions (required)

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. (required)

Yes No N/A

I consent to this allergy and special diet action plan being posted or made available in food prep and classroom areas for safety purposes. (required)

Yes No N/A

I confirm the information provided is accurate and I will notify the childcare center of any changes immediately. (required)

Yes No N/A

Parent/Guardian Signature (required)

Date Signed (required)

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Email (required)

Your name (optional)

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