Allergy

Allergy Care Plan for Gan, Juda, Camp Gan Israel

* 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 symptoms to look out for *

Actions to take *

Name of Medication *

Dosage *

To be administered when... *

Submit

Judaism in South Dakota ... Starts with you!

4901 S Isabel Place
Suite 200
Sioux Falls, SD 57108

605-206-7700

Monday-Friday: 8:00 AM - 3:30 PM
Saturday/Shabbat: Services

Chabad Lubavitch of South Dakota, Inc., is a 501(c)(3). Est., 2016