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Food/Severe Allergy Information Form
To ensure the safety of all students, Ah Haa School for the Arts requests that you complete the following Food Allergy/Severe Allergy Information form. This form allows you to disclose whether you or your child has a food allergy or other severe allergy (bees, latex, grasses etc.) that you believe should be disclosed in order to enable Ah Haa to take necessary precautions for you or your child's safety.
Student Name
*
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Class Name
*
Parent/Guardian Name
First Name
Last Name
Cell Phone
*
Home/Alternate Phone Number
Please select appropriate box below regarding student allergies. If no allergies known, please sign below. If yes, please include additional information below.
No known allergies
Yes, allergies known
Food/Allergy History
Ah Haa staff will maintain the confidentiality of the information provided and may disclose the information to teachers and other applicable school personnel.
Please enter all foods or other irritants that have caused allergic reaction(s)
Please describe the symptoms of the allergic reaction(s)
Are medications required for treatment? (please specify if student carries medication)
Additional notes -- If in a culinary class, please include any dietary restrictions. Important Note: we cannot accommodate all food allergies or dietary restrictions in Culinary Classes.
Signature
Submit
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