Allergy Questionnaire/MJ Campus

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Please answer the following questions regarding your child's allergies.

Email: *

Child's Full Name *

What is your child's allergy? *

Is this allergy to touch, inhalation, ingestion, etc?
*

Is this allergy considered: *

Mild

Moderate

Severe

What medications are needed for this allergy? Epipen? Benadryl?
*

Does your child have an allergy action plan from their MD?
*

Yes

Unsure

Does your child attended our extended care program? *

Yes

If your child attends our extended care program, please check which food we can safely provide for your child with a food allergy. If we add a new food, we will notify you for permission. If you're child attends the 9-2pm program, please disregard this question.

Yes, my child can have this snack option

No, my child can not have this snack option

Apple Sauce

Cheez It, Original

Pop Tarts Bites, Assorted Flavors

Nutri Grain Bars, Assorted Flavors

Rice Krispies Treats

Nilla Wafers

String Cheese

Saltines

Bananas

Yogurt

Milk

Juice (Apple, Orange, Grape, White Grape)

Veggie Straws

Mandarin Oranges

Graham Crackers

Gold Fish

Fruit Snacks

Animal Crackers

Cereal (Cinnamon Toast Crunch, Fruit Loops, Apple Jacks, Kix, Cherrios, etc)

Peaches (canned)