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Allergy & Medical Information Form

Creating a safe, supportive, and engaging learning environment for every student.

Student Name

Date of Birth

Age

Parent/Guardian Name

Phone Number

Emergency Contact

Emergency Contact Phone

ALLERGY INFORMATION

Does your child have any known allergies?

A
B

Type of Allergy
Check all that apply:

Unknown

ALLERGY SEVERITY
Please indicate the typical severity:

A
B
C
D
E
Unknown

Typical Reaction
What symptoms or reactions does your child experience?

EMERGENCY MEDICATION

Does your child require emergency allergy medication?

A
B

If yes, check all that apply:

Medication Name

Dosage

Special Instructions

Will medication be provided to Our Creative™?

A
B
C

FOOD ALLERGY INFORMATION

If your child has a food allergy, please identify the food(s):

Can your child be around the allergen without eating it?

A
B
C

Is cross-contact/cross-contamination a concern?

A
B
C

Does your child require a special snack or meal accommodation?

A
B

If yes, please explain:

ADDITIONAL MEDICAL INFORMATION

Please provide any additional information Our Creative™ staff should know to help keep your child safe:

PARENT/GUARDIAN ACKNOWLEDGMENT

I certify that the information provided on this form is accurate and complete to the best of my knowledge. I understand that it is my responsibility to notify Our Creative™ promptly of any changes to my child's allergies, medications, emergency instructions, or medical needs.

I understand that any required medication must be provided according to Our Creative™ policies and must be properly labeled with the student's name and applicable instructions.

Parent/Guardian Printed Name:

Parent/Guardian Signature:

Signature

Date:

FOR OUR CREATIVE™ STAFF USE

Untitled checkboxes field

Staff Name:

Staff Signature:

Signature

Date Reviewed: