Connecticut Technical High School System

H. H. ELLIS Technical High School

613 Upper Maple Street

Danielson , CT 06239

(860)  774-8511 ext. 1205 /  Fax:  (860) 779-7832

Dear Parent/Guardian:

According to the CTHSS Procedural Plan for Managing Life Threatening Food Allergies ( July 1, 2006 ), it is the responsibility of the parent/guardian to inform the school nurse about any serious or life threatening food allergies your child may have. If your child has a food allergy requiring prescription medication or one that causes swelling of the face and/or throat, itching, vomiting or diarrhea PLEASE fill out the questions below and return it to the school nurse as soon as possible . This information will be used in the process of developing an individual Emergency Care Plan for students who take medication, such an Epi Pen, at school or who have special needs such as allergic reactions. According to the CTHSS Procedural Plan this letter will be sent out twice during the school year. Please remember, it is the parent/guardian's responsibility to notify the school nurse anytime there is a change in the health status of your child. You can reach the school nurse with any questions at (860) 889-8453 ext. 2149. Please make sure you supply 2 doses of the Epi Pen and Benadryl if needed.  

Known Allergies: Peanut___ Tree Nut___ Milk___ Egg___ Fish___ Shellfish_______

Soy____ Wheat___ Other food allergies______________________________________

Bees___ Other Insects____ Latex_________Other:______________________________ 

Describe Reactions both Severe and Subtle:__________________________________ ________________________________________________________________________________________________________________________________________________

Usual Treatment: ________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________  

Epi Pen: Yes____ No____             Benedryl: Yes___ No_____ Other______________ 

Known Asthmatic: Yes_____ No_______  

Student________________________________Address:_________________________

Town_________________________Zip_______________

Daytime phone:____________   Home Phone: ___________________

Parent/Guardian____________________Workphone:__________Cell____________

Parent/Guardian____________________Work phone:__________Cell____________

Other emergency contact________________ Phone:____________Cell____________

Physician____________________________ Phone: ____________________________

Thank you very much for your cooperation.

Sincerely,

Gayle Salisbury, RNC, BSN