Co-op Allergy form 2022-2023

KACHEA CO-OP ALLERGY INFORMATION -- 2022-2023
Child's name
Grade (22/23)
Birth date

Month Day Year
Date
Parent's name
Does your child carry an EpiPen?

Yes No
Do you carry an EpiPen for child?

Yes No
Allergic to:
Severity of allergy:

Sensitivity To: Try to avoid but no major issues with contact Mild: Has a sensitivity to allergan and needs to not eat it Moderate: Can be in the room with but cannot eat or touch Severe: Cannot eat or touch, contact parent if this happens Extreme: Cannot be in the same room, treat and alert parent immediately
How does child react?
Allergic to:
Severity of allergy:

Sensitivity To: Try to avoid but no major issues with contact Mild: Has a sensitivity to allergan and needs to not eat it Moderate: Can be in the room with but cannot eat or touch Severe: Cannot eat or touch, contact parent if this happens Extreme: Cannot be in the same room, treat and alert parent immediately
How does child react?
Allergic to:
Severity of allergy:

Sensitivity To: Try to avoid but no major issues with contact Mild: Has a sensitivity to allergan and needs to not eat it Moderate: Can be in the room with but cannot eat or touch Severe: Cannot eat or touch, contact parent if this happens Extreme: Cannot be in the same room, treat and alert parent immediately
How does child react?
Should be Empty:

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