Allergy Assessment
St. John the Baptist Catholic School
Student Name
First Name
Last Name
What item(s) is/are your student allergic to?
When and how did you first become aware of the allergy?
When was the last time your child had a reaction?
Please describe the signs and symptoms of the reaction.
What medical treatment was provided and by whom?
Name and phone number of the physician treating the allergy.
If medication is required while your child is at school, the School Medication Authorization Form must be completed by the physician and parent. Describe the steps you would like us to take if your child is exposed to this allergen while at school.
Parent/Guardian Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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