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DNS Cooking Camps - Required Allergy Form
This form is required for all children attending camps where food is prepared. Because the safety of your child is our top priority, this form must completed at least two weeks prior to the start of camp. If the completed form is not received, the child will not be able to participate in the cooking camp. If your child has severe allergies, an additional form is required to be filled out by your healthcare provider.
Email address *
Name of Camper *
Name of Person filling out form, and relationship to camper: *
Cooking Camps being attended by child in 2018: *
Required
Does your child have food allergies? *
Food Allergens
If you checked yes above, that your child does have food allergies, please complete the following areas providing as much detailed information as possible.
Please list any and all food allergies that your child has:
Describe the specific reaction of the child to the allergen(s) indicated above:
My child is treated for this reaction with the following medication, include the prescribed dosage:
My child carries their medication with them daily and knows how to self administer their medication:
Does your child have epinephrine?
Does your child have asthma?
If my child has food allergies, I understand that I must provide an Emergency Action Plan form signed by my healthcare provider submitted 2 weeks before the start of camp. By clicking below, I am providing my electronic signature.
Below is the link to FARE's Food Allergy & Anaphylaxis Emergency Care Plan - https://www.foodallergy.org/sites/default/files/2018-04/emergency%20care%20plan.pdf -Once completed and signed by healthcare provider you can upload below or e-mail the completed form to ashley@delnature.org
Healthcare Provider Name and Phone Number
Emergency Contact Information 1 (Name, phone number, relationship to child):
Emergency Contact Information 2 (Name, phone number, relationship to child):
Emergency Contact Information 3 (Name, phone number, relationship to child):
I certify that the information provided on this form is correct to the best of my knowledge and by clicking below, am providing my electronic signature. *
Required
A copy of your responses will be emailed to the address you provided.
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