Allergy & Dietary Information

Child's Name*
First Last
Does your child currently have any of the following allergies? If yes, please describe in detail.
Food Allergies*
- Yes
- No
Description
Medication Allergies*
- Yes
- No
Description
Environmental Allergies*
- Yes
- No
Description
Description
Please list any special dietary requirements your child may have. If your child has allergies or dietary needs we request that you send in a small supply of non-perishable snacks that can be kept in your child's classroom. This allows your child to be included in any class activities involving food. Classroom teaches will also communicate with parents regarding any concerns about a child's allergies or dietary needs.
Parent / Guardian Signature*
First Last
Date*
Date Format: MM slash DD slash YYYY
Pin Number*
CAPTCHA