Allergy Information Form And Action Plan

Academic Year: 2019 - 2020
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Which Division is the student in? *
Emergency contact number(s) for parent(s) listed in priority order. [Ex. 503-246-7771 mom cell]
[use the plus (+) symbol to add up to 2 more rows to the list] *
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Please provide the following information:
 AllergyReactionMedications/treatments
1.
2.
3.
4.
5.
Does your child have an Epinephrine Pen? *
Have you supplied OES with an epi-pen
to be kept in the division office?
Do you authorize your child to carry an epi pen in their backpack? *
Does your child ever ride
the OES bus to or from school: *
The electronic signature below indicates that, as the parent or guardian of the above named student, I authorize an exchange of information to occur between the OES nursing staff and the physician or health care provider listed above.
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