*
Required
Allergy Questionnaire
Student's First Name
*
required
Student's Last
*
required
Allergy
*
required
When was the last time your child experienced Anaphylaxis
*
required
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
*
required
Emergency Contact #
*
required
Emergency Contact Email
*
required
Please send a confirmation email to the address below*: