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 *
Your answer
Homeroom Teacher *
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.
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.
Your answer
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.)
Your answer
Permission to Participate & Summary
Permission to Participate in Food Related Activities *
Medical Conditions, Medications or Food Allergies *
Black Gold Schools Procedure for Medical Procedures or Dispensing Medicine
Parent/Guardian Name (First/Last) *
Your answer
Please inform the office if there are any changes to your child's medical needs.
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