Allergy Form

Student Information

Student First Name

Student Last Name

Select

Male

Female

Grade

Allergy Information

Please describe the allergy or allergies.

Please describe the medications and treatment plan. After submitting this form, you'll also see a link to the Supervising Medications Form, granting Pilgrim permission to administer medications.

Parent/Guardian Information

Primary Parent/Guardian First and Last Name

Primary Parent/Guardian Email

Primary Parent/Guardian Phone

Second Parent/Guardian First and Last Name

Second Parent/Guardian Email

Second Parent/Guardian Phone

By checking this box, I acknowledge and agree...

I give permission to the staff of Pilgrim Lutheran Church and School to care for my child in the event of an allergic reaction. This care may include monitoring for symptoms and providing comfort care, such as an area to rest or ice pack.
If provided with an allergy medication and the Supervising Medications Form is complete (linked after form submission), Pilgrim staff may administer the medication.
If the symptoms are severe, Pilgrim staff may perform life saving care and call for emergency medical services (911).
I release Pilgrim Lutheran Church and School and staff from liability, should an adverse reaction result.

Type Name (Serves as Signature)

Today's Date