Allergy form

ALLERGY FORM

THE FAMILY GUIDANCE AND THERAPY CENTER
Program Participant Name:
Program Participant Date of Birth:
1. Please list any and all food, environmental and/or medication allergies your child has:
2. Please list the symptoms your child would exhibit as an allergic reaction to each of the allergies noted question 1 above:
Primary Care Physician Contact information:
Name:
Phone:
Emergency Contact Information: Please list an emergency contact (other than the parent):
Full Name:
Primary Phone:
Relationship to client:
Parent/guardian understands that The Family Guidance and Therapy Center of Southern California (FGTC) personnel may not, under any circumstances administer medication or provide emergency medical services. The FGTC program personnel will bring allergic reaction to the parent's/legal guardian's attention. It is the parent's/legal guardian's responsibility to decide how best to proceed, if any medication should be administered, and to administer medication if it is deemed appropriate. The FGTC program personnel have been instructed to dial 9-1-1 when in their judgment the parent legal guardian is not present or is unable to address and resolve the situation quickly and successfully.

Parent's/legal guardians agree to release, indemnify and defend The Family Guidance and Therapy Center of Southern California., its employees, subcontractors and agents from and against any claim for any losses, expenses, damages or injuries arising out of or in connection with an allergic reaction incident involving my child.
Parent Name
Parent Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

ALLERGY FORM