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Anaphylaxis Form

Signs & Symptoms:

1. Skin – Hives, swelling (face, lips, tongue) intching, warmth, redness

2. Respiratory System – Coughing, Wheezing, shortness of breath, chest pain or tightness, throat tightness, hoarse voice, nasal congestion or hay fever symptoms, trouble swallowing

3. Gastrointestinal – nausea, pain or cramps, vomiting, diarrhea

4. Cardiovascular – pale skin, blue colour, weak pulse, passing out, dizziness, light-headedness, shock

5. Other – anxiety, sense of impending doom, headache, uterine cramps, metallic taste in mouth

 

Emergency Protocal:

1. Give epinephrine auto-injector at first sign of a known or suspected anaphylactic reaction

2. Call 911 and inform dispatcher of situation

3. Give second dose of epinephrine after the first dose is patient does not improve or worsens

4. Get to nearest hospital (ideally by ambulance) even if symptoms are mild or have stopped.

5. Call Hoodoo Adventures (General Manager or Youth Program Manager) to contact emergency contacts.

The undersigned patient, parent, or guardian, authorizes any adult to administer epinephrine to the above named person in the event of an anaphylactic reaction. The patient’s physician has recommended the above protocol, or attached an alternative.

 

  June 18, 2021

 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Doctor's Information:

Doctor's Name:

Doctor's Phone Number:
Life Threatening Allergen:

Food:

Insect or Environmental:

Other:
Medical Management:

Dose 1:


Location:

Dosage:
Epi-pen
Allerject
Other

Dose 2:


Location:

Dosage:
Epi-pen
Allerject
Other
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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