Zarephath Christian Academy Allergy Information Form

Please fill out the following form to provide us with important details regarding your child's allergies. This information is vital to ensure your child's safety and well-being while attending our school.

Student Name

Date of Birth

Grade

Parent/Guardian

Phone

Please list all known allergies (food, medication, environmental, etc.):

Please describe the symptoms your child experiences when exposed to the allergen(s):

Does your child require medication for their allergy?

Yes

If yes, please list the medication(s) and instructions for administration:

Does your child carry an EpiPen or other emergency medication?

Yes

If yes, please provide specific instructions for its use:

Are there any foods or environmental triggers that should be avoided while your child is at school?

Emergency Contact Information:

Emergency Contact Name

Relationship to Student

Phone Number

Alternate Phone Number

Parent/Guardian Acknowledgment: I understand that it is my responsibility to notify the school immediately if there are any changes to my child's allergy information or treatment plan. I give permission for the school to take necessary actions, including the administration of medication in case of an allergic reaction, according to the instructions provided.

Signature

Signature field is empty.

Date

Month

Day

Year