Allergy Form

Child's Name, Age, and Current Grade *
List of Allergies (please indicate if allergy is mild, moderate, or severe) *
In the event of an allergic reaction, who should be contacted? (please include name, relation to child, phone, and email) *
What are the signs of a reaction? *
I am providing the following medication(s) for my child to a PCM staff member (all medications must be labeled with child's name) *
What is the protocol for a reaction?
Parent/Guardian Name: *
Today's Date:*