Severe Allergy Form

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Severe Allergy Form

Student Name *

Your student's grade and school *

My student is allergic to... *

Has your student been prescribed epinephrine? *

Yes

If prescribed epinephrine, does your student carry their own pen? *

Yes

Can your student be near other students when they're eating this food allergen (for example, at the same lunch table)? *

Can your student eat food produced in a facility that processes this food allergen? *

Does your student require a nut-free classroom? *

Will your student bring lunch and snacks from home? *

Does your student take the bus to or from school? *

Yes

Does your student participate in any off-campus, school activities? *

Yes

Please provide your preferred way to reach you if we have questions. *

Is there anything else you'd like us to know?

Submit

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