Request for Food Allergy Information - House Bill 742
This form allows you to disclose whether your child has a food allergy or severe food allergy that you believe should be disclosed to the District in order to enable the District to take necessary precautions for your child's safety.
"Severe food allergy" means a dangerous of life-threatening reaction of the human body to a food-borne allergen introduced by inhalation, ingestion, or skin contact that requires immediate medical attention.
Last name of student
First name of student
Date of birth
Please choose one of the following options:
My child does not have a food allergy.
My child has a food allergy or severe food allergy that in my judgement should be disclosed to the district to enable the district to take any necessary precautions regarding the child's safety.
My child uses an Epi Pen
Please list any foods to which your child is allergic or severely allergic as well as the nature of your child's allergic reaction to the food.
This district will maintain the confidentiality of the information provided above and may disclose the information to teachers, school counselors, school nurses, and other appropriate school personnel only within the limitations of the Family Education Rights and Privacy Act and District policy. Please notify your child's school nurse if there are any significant changes in the child's food allergy information.
I have read and understand the above statement.
Parent Primary Phone
By typing your name below, you are electronically signing this document.
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