2018-19 Allergy and Dietary Information

Allergy and Dietary Information
Student's Name *

First Name Last Name
Does your student currently have any of the following allergies? If yes, please describe in detail.
Food allergies *

Yes No
Description
If yes, please upload your student's allergy action plan

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Medication allergies *

Yes No
Description
Environmental allergies *

Yes No
Description
Please list any special dietary requirements your child may have.
Description
If your student has allergies or dietary needs we request that you send in a small supply of non-perishable snacks that can be kept in your student's classroom. This allows your student to be included in any class activities involving food. Classroom teachers will also communicate with parents regarding any concerns about a student's allergies or dietary needs.
Parent/Guardian Signature *

First Name Last Name
Date *

Month Day Year
Student Birthdate *
Enter the message as it's shown *
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Should be Empty: