Food Allergies, Intolerances, and Avoidances

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

****PLEASE READ****
Food ALLERGIES are NOT the same as food intolerances or avoidances. An allergic reaction can be a dangerous and/or life threatening situation where seconds and minutes matter. It is important to know if there are any children with SEVERE food allergies and differentiate them from those who simply avoid certain foods.

Student's Full Name

If you have more than one child with an allergy/intolerance/avoidance, please complete this form for EACH child individulally.

Please check those that apply:

SEVERE FOOD ALLERGY

MILD FOOD ALLERGY

FOOD INTOLERANCE

FOOD AVOIDANCE

Other:

Allergy/Intolerance/Avoidance

Wheat/Gluten

Peanuts

Tree Nuts

Milk

Dairy

Corn

Eggs

Soy

Fish

Shellfish

Other:

2. If your child accidentally ingests an allergen, will they require immediate medical treatment?

YES, my child will need immediate medical attention.**

NO, they might experience an allergic reaction, but will MOST LIKELY NOT require medical attention.

No action is necessary, but I would like to be informed as soon as possible.

No, my child should not experience any sudden reactions.

Other:

**If your child has a severe food allergy that may require medical attention, please explain your action plan.

Emergency Contact(s)

Person(s) most likely to be present at MLC events with this student.

Emergency Phone Number(s)

Provide Cellular Phone Number(s), if possible.

Additional Comments:

Allergy Disclaimer:

MLC makes every effort to not serve ingredients that may cause allergic reactions for those individuals with food allergies. However, any/all members may bring food into MLC that any student member could come into contact with. Members concerned with food allergies must be aware of this risk. MLC cannot assume any liability for adverse reactions to food consumed, or items one may come in contact with while eating at any MLC facility or event. Students/Members with life threatening food allergies who may need to use an epi-pen should be carrying their own. MLC members are NOT trained to administer epi-pens and CANNOT provide or administer them.

PLEASE CLICK "SUBMIT" BELOW.

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This content is neither created nor endorsed by Google.