College for Kids/Teens Allergy Form

College for Kids/Teens Allergy Form
This form is only needed if your child has an allergy.
Student Name*

First NameLast Name
Student's Date of Birth*

MonthDayYear
Date
Start Date of Student's Camp/Workshop*

MonthDayYear
Date
End Date of Student's Camp/Workshop*

MonthDayYear
Date
Class/Camp Title*
Parent/Guardian's Name*

First NameLast Name
Relationship to Student*
Parent/Guardian's Phone Number*
Format: (000) 000-0000.
Parent/Guardian's Alt Phone Number
Format: (000) 000-0000.
Parent/Guardian's Email*
example@example.com
List Allergy(ies)*
Is an EpiPen required for allergic reaction? If yes, please see MCC staff on the first day of camp to provide an EpiPen for the child while camp is in session.*

YesNo
Is there any other information you would like to share with us in regard to allergies?
Please note: Courses held at MCC are held in many different locations including commercial kitchens, schools college campuses with allergens present, and while all efforts possible will be made to keep students out of direct contact with allergens, no room can be guaranteed as allergen free.
Should be Empty: