Allergy Form

Please complete this form if your child has any allergies. If your child has multiple food allergies, please complete one form for each food

ALLERGY TO:*
For children with multiple food allergies, please complete one form for each food allergy.
Child's Name*
First Last
Child's Birth Date*
MM slash DD slash YYYY
Child's Class*
Asthmatic?
- Yes (high risk for severe reaction)
- No
ACTION:
If ingestion is suspected, what actions should be taken? If medication, please indicate the name of the medication, the dosage, and any other pertinent information. Please note if any other actions should be taken.
Emergency Contact Information
Parent's Name
First Last
Parent's Phone Number
Alternate Phone for Parent
Parent's Name
First Last
Parent's Phone Number
Alternate Phone for Parent
Doctor
First Last
Doctor's Phone Number
Emergency Contacts
Please list three emergency contacts, for use in the event a parent cannot be reached. Include name, phone number(s), and relationship to the child.
Signature

I hereby grant permission for the director or supervisors staff person to take whatever steps may be necessary to obtain emergency medical care if warranted. These steps may include, but are not limited to, the following: 1. Attempt to contact a parent or guardian. 2. Attempt to contact the child's physician. 3. Attempt to contact a parent through any of the persons listed on the emergency information form you completed for us. 4. If we cannot contact you or your child's physician, we will do any or all of the following: (a) call another physician or parademics; (b) call an ambulance; (c) have the child taken to an emergency hospital in the company of a staff member. 5. Any expense under 4, above, will be borne by the child's family.
Date
MM slash DD slash YYYY

Allergy Form

Emergency Contact Information

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St. John’s Church (Episcopal)

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