Allergy/Intolerance Care Plan Form

This form is required if your child has an allergy/intolerance to ensure that our colleagues can support them fully whilst at nursery.

Child's details

Child's name(Required)

First Last

Child's date of birth(Required)

Nursery attending(Required)

Does your child have more than one allergy or intolerance?(Required)

Yes

Allergy/intolerance details

How many allergies/intolerances does your child have?

Two

Three

More than three

Unfortunately you can only add 3 allergies and/or intolerances on this form and you will have to complete another form for any not listed here

What is the specific allergen, allergy, or intolerance? (Please state allergy or intolerance against each item)

Has your doctor (or a specialist) been involved in the management of the allergy/intolerance?

Yes

Has the family doctor or specialist confirmed details of the allergy/Intolerance in writing to you, and are you able to share this with the nursery?

Yes

Does the child require an EpiPen or other medication in connection with the allergy or intolerance to be kept at the nursery, please list:

What are the symptoms of the allergic/intolerance reaction?

How is your child’s allergic/intolerance reaction triggered? (Please select all that apply)

Ingestion

Touch

Proximity

Sting

Can your child consume foods from packaging that states, “May Contain…”?

Yes

How many times has the child suffered a reaction, and when was the last episode?

Allergy/intolerance 1

1. What is (are) the specific allergen, allergy, or intolerance? (Where there is more than one please list in order of severity and state allergy or intolerance against each item)

1. Has your doctor (or a specialist) been involved in the management of the allergy/intolerance?

Yes

1. Has the family doctor or specialist confirmed details of the allergy/Intolerance in writing to you, and are you able to share this with the nursery?

Yes

1. Does the child require an EpiPen or other medication in connection with the allergy or intolerance to be kept at the nursery, please list:

1. What are the symptoms of the allergic/intolerance reaction?

1. How is your child’s allergic/intolerance reaction triggered? (Please select all that apply)

Ingestion

Touch

Proximity

Sting

1. Can your child consume foods from packaging that states, “May Contain…”?

Yes

1. How many times has the child suffered a reaction, and when was the last episode?

Allergy/intolerance 2

2. What is (are) the specific allergen, allergy, or intolerance? (Where there is more than one please list in order of severity and state allergy or intolerance against each item)

2. Has your doctor (or a specialist) been involved in the management of the allergy/intolerance?

Yes

2. Has the family doctor or specialist confirmed details of the allergy/Intolerance in writing to you, and are you able to share this with the nursery?

Yes

2. Does the child require an EpiPen or other medication in connection with the allergy or intolerance to be kept at the nursery, please list:

2. What are the symptoms of the allergic/intolerance reaction?

2. How is your child’s allergic/intolerance reaction triggered? (Please select all that apply)

Ingestion

Touch

Proximity

Sting

2. Can your child consume foods from packaging that states, “May Contain…”?

Yes

2. How many times has the child suffered a reaction, and when was the last episode?

Allergy/intolerance 3

3. What is (are) the specific allergen, allergy, or intolerance? (Where there is more than one please list in order of severity and state allergy or intolerance against each item)

3. Has your doctor (or a specialist) been involved in the management of the allergy/intolerance?

Yes

3. Has the family doctor or specialist confirmed details of the allergy/Intolerance in writing to you, and are you able to share this with the nursery?

Yes

3. Does the child require an EpiPen or other medication in connection with the allergy or intolerance to be kept at the nursery, please list:

3. What are the symptoms of the allergic/intolerance reaction?

3. How is your child’s allergic/intolerance reaction triggered? (Please select all that apply)

Ingestion

Touch

Proximity

Sting

3. Can your child consume foods from packaging that states, “May Contain…”?

Yes

3. How many times has the child suffered a reaction, and when was the last episode?

Signature(Required)

Your name

First Last

Name

This field is for validation purposes and should be left unchanged.

Cedars Day Nursery - Leighton Buzzard

We prioritise the importance of outdoor play at Cedars Day Nursery in Leighton Buzzard. All children at our Ofsted-rated ‘Outstanding’ nursery have access to our large, natural garden area on a daily basis as we recognise the impact that being outdoors has on a child’s social, emotional and physical development. The children enjoy planting vegetables and tasting their produce, served by our dedicated Nursery Chef.

Cedars Day Nursery, Mentmore Rd, Leighton Buzzard LU7 2PA

Tel: 01525 850200

Email: cedars.nursery@childbase.com