Co-op Allergy form 2023-2024

KACHEA CO-OP STUDENT ALLERGY INFORMATION

2023-2024

Please complete a form for each of your students. If no allergies, input "None".

Child's name

Grade (23/24)

Birth date

Date

Parent's name

Does your child carry an EpiPen?

YesNo

Do you carry an EpiPen for child?

YesNo

Allergic to:

Severity of allergy:

Sensitivity To: Try to avoid but no major issues with contactMild: Has a sensitivity to allergan and needs to not eat itModerate: Can be in the room with but cannot eat or touchSevere: Cannot eat or touch, contact parent if this happensExtreme: 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 contactMild: Has a sensitivity to allergan and needs to not eat itModerate: Can be in the room with but cannot eat or touchSevere: Cannot eat or touch, contact parent if this happensExtreme: 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 contactMild: Has a sensitivity to allergan and needs to not eat itModerate: Can be in the room with but cannot eat or touchSevere: Cannot eat or touch, contact parent if this happensExtreme: Cannot be in the same room, treat and alert parent immediately

How does child react?