Allergy Form

Allergy Form
Child's Name: First Name* Last Name* Date of Birth: Date
Please list any of your child’s allergies and any medical conditions that your child may have.
Food:
Medications:
Any other substance that may cause an allergic reaction:
If my child has an allergy, I authorize my child’s name may be posted in the therapy rooms as a reminder to staff to prevent allergic reactions. This is very important to keep your child as safe as possible and involved in a healthy environment.
Parent/Guardian's Signature*

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