School of the Art Institute of Chicago
Continuing Studies
36 South Wabash Avenue, suite 1201
Chicago, IL 60603
Email: ecp@saic.edu
Phone: 312.629.6170 Fax: 312.629.6171
ALLERGY HISTORY & INFORMATION FORM
Complete this form only if your child has an allergy that may require emergency assistance. If emergency medication may be required
while your child is at SAIC, an Emergency Action Plan (EAP) form must be completed by your child’s physician and submitted prior to
the start of class. SAIC sta members are not able to administer emergency medication without a completed Emergency Action Plan
on file from your child’s physician.
STUDENT NAME (PLEASE PRINT): ID NUMBER:
ALLERGENS:
WHEN AND HOW DID YOU FIRST BECOME AWARE OF THE ALLERGY?
WHEN WAS THE LAST TIME YOUR CHILD HAD A REACTION?
PLEASE DESCRIBE THE SIGNS AND SYMPTOMS OF THE REACTION:
WHAT MEDICAL TREATMENT WAS PROVIDED, AND BY WHOM?
SAIC sta members are not trained medical professionals. However, they have been trained to administer EpiPens in the event of
an emergency. For students enrolled in the Children’s Workshops, parents are required to provide SAIC with an EpiPen to be stored
on-campus for the duration of their child’s class. The EpiPen must be clearly marked with the child’s name. For Middle School and
Early College Program students, SAIC expects that the students will carry their own medication.
SAIC sta members will only administer medication in the event of an emergency. All other non-emergency medication should be
self-administered or be arranged to be administered by parents.
Please note that SAIC sta are not able to administer over-the-counter (non-prescription) medication, even if a physician indicates
use of said medication in the student’s Emergency Action Plan (EAP). If non-prescription medication is indicated on a student’s EAP,
parents will be asked to follow up with their physician to update the form.
PARENT/GUARDIAN NAME (PLEASE PRINT): PARENT/GUARDIAN SIGNATURE: DATE:
click to sign
signature
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