Allergy Alert
Pre-K to 12th Grade Students
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_________________________ is allergic to: _________________________
name Please write NONE if your child has no allergies.
_________________________ is allergic to: _________________________
name Please write NONE if your child has no allergies.
________________________ is allergic to: _________________________
name Please write NONE if your child has no allergies.
________________________ is allergic to: _________________________
name Please write NONE if your child has no allergies.
________________________ is allergic to: _________________________
name Please write NONE if your child has no allergies.
_______________________________________________________________
Info below is for 6th Grade and Above ONLY!
Faculty members of BHSE are permitted to administer:
Tylenol _____ Ibuprofen _____ Aspirin _____
in the case of:
Headache _____ Body Ache _____
Y / N I would like to be called before any medication is administered.
(circle one)
Parent’s Signature: ____________________________ Date: _______
Please list any other information relating to this topic on the back.