Bee/Insect Allergy Form

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Please complete regarding your child's listed insect allergy

Email *

Child's First and Last Name *

Parent/Guardian Phone Number:

Do you think your child's bee/insect allergy may be life threatening?

Yes

Clear selection

What type of stinging bee or insect has your child reacted to?

How many times has your child had a reaction? *

Never

Once

More than once, please describe below

If you chose "more than once" for your child's reactions, please describe here:

When was the last reaction?

Are the reactions:

Staying the same

Getting worse

Getting better

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Has your child ever needed treatment at a clinic or hospital for an allergic reaction? *

Yes, please describe below

If you checked "Yes" for receiving treatment at clinic or hospital, please explain here:

What are the signs and symptoms of your child's reaction? Please include things your child might say

What do you do at home if there is a reaction to a bee sting or insect bite? *

What treatment or medication has your doctor recommended for an allergic reaction?

Have you used the treatment or medication? *

Yes

Does your child know how to use the treatment or medication? *

Yes

Please describe any side effects or problems your child has had in using suggested treatment

If medication is to be available in school, have you had the doctor fill out the medication form for school? *

Yes

No, I need to get the form, have it completed by the doctor and return to school nurse

I will not be providing emergency medication to the school

What do you want the school to do in case of a bee sting or insect bite? *

Parent/Guardian signature and date *

Submit

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