Medical or Food Allergen Form
In the interest of providing a safe learning environment for your child, please indicate whether or not your child has any medical conditions , requires medication at school or has a sensitivity to certain food allergens.
Student First & Last Name
Medical Alert Condition
If your child has a medical alert condition, you must complete a Severe Medical Form and/or other necessary documentation. These forms will be sent home after this sheet has been completed.
A Medical Alert Condition is defined as a physician diagnosed, potentially life threatening condition such as:
Please check off any severe medical conditions that your child has.
Diabetes (student must carry their medical supplies on them at all times.)
Analyphylaxsis (severe allergic reaction - student must carry epi-pen on them at all times)
Severe asthma (student must carry their medication on them at all times)
Blood Clotting Disorders
Serious Heart Conditions
My child does not have any severe medical conditions.
Food or Other Allergens -Severe Allergic Reaction
Please list all food allergens or other allergens that would cause your child to have an analphylaxis reaction.
Other Allergens (non life threatening)
Allergies/Sensitivity to Food or Other Items
Classes may have food related or other activities. Please list any other allergies (non life threatening) that your child might have and possible reactions. (Ex: Grass, animals, food sensitivity etc.)
Permission to Participate & Summary
Permission to Participate in Food Related Activities
I do not wish my child to participate in food related activities.
My child has permission to participate in any food related activities.
Medical Conditions, Medications or Food Allergies
My child DOES NOT have any medical conditions or food allergies.
My child HAS a medical condition or food allergies as listed above.
My child requires medication or medical procedures at school.
Black Gold Schools Procedure for Medical Procedures or Dispensing Medicine
Parent/Guardian Name (First/Last)
Please inform the office if there are any changes to your child's medical needs.
Never submit passwords through Google Forms.
This form was created inside of Black Gold Regional Schools.
Terms of Service