Connecticut Technical High School System

Eli Whitney Technical High School

71 Jones Road

Hamden, Connecticut 06514

(203) 397-4050

Dear Parent/Guardian:

The health records have been reviewed and I noticed that your son or daughter has allergies. Please let know the extent of the allergies and the protocol you have have used over the years. This information will be used in the process of developing an individual Emergency Care Plan for students who take medication, as an example, Epi Pen, at school or have special needs such as allergic reactions. Enclosed is a Medication Administration form that your physician will need to fill out for medication needed, such as an Epi Pen, Benedryl or any other medications needed at school. Please make sure you supply 2 doses of the Epi Pen and Benedryl if needed.

Known Allergies: Peanut___ Tree Nut___ Milk___ Egg___ Fish___ Shellfish___ Soy____ Wheat___
Other food allergies_______________________________________
Bees___ Other Insects____ Latex_________Other:______________________________

Potential Unknown Allergies: ________________________________________________

Known Asthmatic: Yes_____ No_______

Describe Reactions both Severe and Subtle:__________________________________ _______________________________________________________________________
_______________________________________________________________________

Usual Treatment: ________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Epi Pen: Yes____ No____ Benedryl: Yes___ No_____ Other______________

Student________________________________Address:___________________________

Town_________________________Zip_______________Daytime phone:____________

Parent/Guardian______________________Work phone:__________Cell____________

Parent/Guardian______________________Work phone:__________Cell____________

Other emergency contact____________________ Phone: ____________Cell____________

Physician____________________________ Phone: ____________________________

Thank you very much for your cooperation.
Sincerely,

Palma Shea, RN

Head Nurse