Allergy Alert Form Allergy alert!Please fill out all of the fields below. Child's Name * First Name Last Name Enter Allergies Here Enter What Treatment is Required for This Allergy Checkbox Mild Moderate Severe Complete By By printing your name, you are acknowledging the printed name on these documents will act as your temporary authorization and we will require you to sign the documents in person): Your Name First Name Last Name Relationship e-Signature Typing in your name below qualifies as your e-signature. Date MM DD YYYY Thank you!
