Allergy Notification Form
This form should be completed by the parent or guardian of students.
Student's Name
First Name
Last Name
Student's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Does your child have any food allergies or intolerances?
Yes
No
Please select your child's food allergies below.
Please state.
If you ticked any of the above boxes please provide further details of the nature of the allergy/intolerance:
Does your child carry an EpiPen or autoinjector?
Yes
No
Name of Parent/Guardian
First Name
Last Name
Phone Number Parent/Guardian
Please enter a valid phone number.
Format: (000) 000-0000.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: