Allergy

Allergy Care Plan for Gan Early Learning Center and JUDA Enrichment

* Indicates required field

Name *

First

Last

Date of Birth *

Food Allergies *

YES NO

Please list all foods your child is allergic to *

Other allergies or medical conditions: *

Please detail any cross contamination issues we should be aware of *

Please list any precautions needed (such as needing to eat in a separate room) *

Medication *

Epipen Other Medication Epipen or other medication needs refrigeration?

Please detail symtoms to look out for *

Actions to take *

Name of Medication *

Dosage *

To be administered when... *

Submit