Legal Rights of Children with Epilepsy in School & Child Care

CHILD CARE SEIZURE DISORDER EMERGENCY TREATMENT PLAN
Center #
Directions: Whenever a child with a seizure disorder is enrolled we require that the following information be provided so
that the best possible care can be obtained for your child. The first section is to be completed by the parent or guardian.
The next is to be completed by the physician treating the child for the disorder. The Center Director completes the third
section. Your child can start attending when all sections are completed and the form returned.
Student’s Name
Date of Birth
Emergency Contacts – Please list three emergency contact numbers in the order you would like to have them called.
Parent or guardian must provide valid contacts and keep them updated as needed. Failure to do so may result in
disenrollment.
Parent Phone # Phone#
Parent Phone# Phone #
Name Relationship Phone #
Name Relationship Phone #
Name Relationship Phone #
History of Seizure Disorder ______________________________________________________________________
_______________________________________________________________________________________
Describe “typical” seizure behavior _______________________________________________________________
_______________________________________________________________________________________________
Triggering Stimuli
Warning Signals
___ heat/cold ___ injury ___ none ___ nausea/vomiting
___ low BS ___ psychosocial issues ___ cold ___ tremor
___ fatigue ___ light ___ numbness ___ auditory aura
___ fever ___ hyperventilation ___ tingling ___ visual aura
___ unknown ___ headache ___ smell/taste aura
Other Comments__________________________
Other Comments______________________________
Current Medications – Please list all medications, including prescription, over the counter and herbal preparations, and
indicate the dosage that your child is currently taking.
Dietary Restrictions _______________________________________________________________________________
_________________________________________________________________________________________________
Seizure Disorder Emergency Treatment Plan
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