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?
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