Severe Allergy Form
Sign in to Google to save your progress. Learn more
Student Name *
Your student's grade and school *
My student is allergic to... *
Has your student been prescribed epinephrine?  *
If prescribed epinephrine, does your student carry their own pen?  *
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? *
Does your student participate in any off-campus, school activities? *
Please provide your preferred way to reach you if we have questions. *
Is there anything else you'd like us to know? 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Philomath School District 17J. Report Abuse