Child's Name * First Name Last Name Parent/Guardian * First Name Last Name Parent/Guardian * First Name Last Name HEALTH INFORMATION This child has a DANGEROUS, life-threatening allergy to the following: * ...and all substances containing them in any form or amount, including the following kinds of items: Include what medication you are providing; where it is located; is it given to staff? Symptoms following exposure to a particular material can include: * Check all that apply. hives and itchiness on any part of the body nausea, vomiting, diarrhea difficulty breathing or swallowing panic or sense of doom throat tightness or closing swelling of any body parts, especially eyelids, lips, face or tongue coughing, wheezing, or change of voice fainting or loss of consciousness Other I understand why I have been asked to disclose the above information and I am aware of the risks or benefits of consenting or refusing to consent to this disclosure. I voluntarily agree that Education Explorers may post my child/teen’s picture, take the Emergency Measures, and share this information, as necessary, with health providers. * Yes, I have read and agree Thank you!
