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Primary & Intermediate Food Allergy Form

Student Last Name*

Answer required for "Student Last Name"

Student First Name*

Answer required for "Student First Name"

Classroom Teacher*

Answer required for "Classroom Teacher"

School Year*

example: 2026-2027

Answer required for "School Year"

Allergy*

Answer required for "Allergy"

Reaction*

Answer required for "Reaction"

Date of last reaction*

Answer required for "Date of last reaction"

Emergency Medication(s) in the office*

Answer required for "Emergency Medication(s) in the office"

ALLERGY TABLE AT LUNCH*

Answer required for "ALLERGY TABLE AT LUNCH"

Yes, I want my child to be assigned to the allergy table for lunch. I understand that other students at this table will also have food allergies.

No, I do not want my child to be assigned to the allergy table for lunch. I understand that he/she will be sitting next to other students who may have food that my child is allergic to.

TREATS FOR THE CLASSROOM*

Answer required for "TREATS FOR THE CLASSROOM"

I will provide treats for my child to be kept in the classroom and used when there are any parties or birthday celebrations.

I will NOT be providing treats for my child to be kept in the classroom. I am ok with my child receiving ANY treat brought in for classroom parties and birthday celebrations. I understand that teachers and staff will not be checking labels.

Parent Name*

Answer required for "Parent Name"

Signature*

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"