Military Allergy Waiver Form
Complete this form to record allergy information and acknowledge the allergy-related waiver for military use. Use the exact form title consistently throughout the form.
Service Member Information
Full Name
*
First Name
Middle Name
Last Name
Military Branch / Unit / Organization
*
Rank / Position
*
Preferred Contact Method
Please Select
Email
Phone
Either
Allergy and Medical Disclosure
Allergy Type(s) or Triggers
*
Pollen
Dust
Pet Dander
Food
Medication
Insect Stings
Latex
Mold
Other
Severity Level
*
Mild
Moderate
Severe
Known Reaction Symptoms
*
Current Allergy Management or Emergency Action Plan
Waiver Acknowledgment and Signature
Signature
*
Submit Military Allergy Waiver Form
Submit Military Allergy Waiver Form
Should be Empty: