Allergy Questionnaire

Student's First Name*

Student's Last*

Allergy*

When was the last time your child experienced Anaphylaxis*

Where would you prefer your child's Epi-Pen located during school hours?*

Nurse's office (Please supply Epi-Pen to school nurse on orientation day.) With my child Both (Please supply 2 Epi-Pens on orientation day.)

Emergency Contact Name*

Emergency Contact #*

Emergency Contact Email*