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ALLERGY ALERT PAGE

This page is designed for parents of children with allergies. Our first priority at STEM Academy is your child’s safety. Please help us by completing the information below and speaking directly with the center director concerning your child’s allergy.

child first name :

child last name :

List known ALLERGY/ALLERGIES below: :

Does your child have an EPI pen?

No

Yes

Does your child use Benadryl?

No

Yes

Have you supplied the center with Benadryl and/or Epi pen in the original box with your child’s information label on it?

No

Yes

Did your doctor fill out an allergy action plan?

No

Yes

PARENT’S OF CHILDREN WITH ALLERGIES MUST DISCUSS ANY/ALL DIETARY ISSUES WITH THE DIRECTOR UPON ENROLLMENT. WE STRONGLY ENCOURAGE PARENTS OF CHILDREN WITH ALLERGIES TO SUPPLY ALL THEIR CHILD’S FOOD AND BOWLS.

Parent/Guardian Signature:

Date :

Director Signature :

Date :

STEM Academy for Young Kids

application form

ALLERGY ALERT PAGE