Student Allergy & Dietary Restriction Form 2026-2027

Student Name

First NameLast Name

Grade

Date of Birth

Date

Parent/Guardian Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Does your child have any food allergies?

Allergen

Reaction Type (e.g., hives, anaphylaxis)

Requires EpiPen

Allergen

Reaction Type (e.g., hives, anaphylaxis)

Requires EpiPen

Allergen

Reaction Type (e.g., hives, anaphylaxis)

Requires EpiPen

Additional details or instructions:

Does your child have any seasonal/environmental allergies?

Allergens (e.g., pollen, grass, dust)

Reaction Type

Requires Medication

Allergens (e.g., pollen, grass, dust)

Reaction Type

Requires Medication

Medication Name(s) and Instructions (if applicable):

Does your child have any drug/medication allergies?

Allergen

Reaction Type

Requires Medication

Allergen

Reaction Type

Requires Medication

Additional details or instructions:

Does your child have an Emergency Action Plan on file with the school's Office?

Emergency Medication Provided to School (e.g., EpiPen, inhaler):

Medication Name(s) and Instructions (if applicable):

Primary Physician Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Hospital

In the event that child name* requests a pain reliever, I authorize Victory Christian Academy to dispense a dose, as specified on the label, of acetaminophen (e.g., Tylenol) to the student. I also commit, as a parent/guardian, to providing this medication to the school office in its original, clearly labeled container.

I give permission for my son/daughter to be given cough drops as needed during school hours. I agree to supply the school with the cough drops in their original, clearly labeled packaging.

Please be advised in the case of a medical emergency where a Parent or guardian cannot be reached, Victory Christian Academy will call an ambulance for your child.

Parent/Guardian Authorization

I certify that the information provided above is accurate and complete. I understand it is my responsibility to notify the school of any changes to my child’s medical information and to provide all relevant medical paperwork and plans.

I understand and agree that Victory Christian Academy will not be held responsible for any adverse reactions or outcomes resulting from emergency medical treatment.

Parent Name

First NameLast Name

Signature

Date

Student Allergy & Dietary Restriction Form 2026-2027

Student Information

Food Allergies

Seasonal or Environmental Allergies

Drug/Medication Allergies

Emergency Action Plan

Medical and Health Information

Authorization to Dispense Over-the-counter Pain Reliever

Authorization for Cough Drops