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Severe, Life Threatening Allergy Protocol Registration <br /> (References: P.108.SCO and PR.548.SCO) <br />NOTE: Please type and submit the original, signed copy to your child’s school principal in a <br />timely manner. In the case of ongoing serious medical conditions (such as but not limited to <br />severe, life-threatening allergies, diabetes, epilepsy, heart condition, asthma), this <br />authorization w ill terminate on June 30 of each school year. Please ensure to notify the <br />principal if the prescription changes or expires. This authorization may be cancelled upon <br />receipt of written notification to the principal. <br />School Name: Date: <br />Principal’s Name: Home Form Teacher’s Name: <br />Student’s Name: Student No.: <br />Year/Grade: <br />Location of Auto-Injector on Student: <br />Pick-up/Drop-off Bus Route Numbers: <br />Transportation Address: <br />STUDENT’S PHOTO: PLEASE ATTACH A RECENT PHOTO OF STUDENT TO FORM <br />ALLERGIES: <br />Anaphylactic reaction (life-threatening) to (specify): <br />SYMPTOMS <br />An anaphylactic reaction can begin within seconds or exposure or after several hours. Any <br />combination of the following symptoms may signal the onset of a reaction. Please indicate symptoms <br />to watch for: <br />Hives <br />Itching (on any part of the <br />body) <br />Swelling (of any body <br />parts, especially eyes, <br />lips, face, tongue) <br />Red watery eyes <br />Runny nose <br />Vomiting <br />Diarrhea <br />Stomach cramps <br />Change of voice <br />Coughing (could sound <br />like throat clearing) <br />W heezing <br />Throat tightness or <br />closing <br />Difficulty swallowing <br />Difficulty breathing <br />Sense of doom <br />Dizziness <br />Fainting or loss of <br />consciousness <br />Change of colour <br />Other <br />OCDSB 616 School Operations (June 2014) Confidential W hen Complete <br />Page 1 of 4 <br />Distribution: OSR