J4TH Suspected Allergy & Food Intolerance Form

SUSPECTED ALLERGY & FOOD INTOLERANCE FORM
This form is to be completed by the parent/guardian when the parent/guardian suspects their child may be allergic to a product or has a food intolerance, but has not been formally diagnosed, or has not been given a health care plan from their medical provider.

Note: If the suspected allergy or food intolerance is medically diagnosed, a Health Care Plan completed and signed by the child’s physician is required. Just 4 Kids will provide this form for your convenience.
Child's Name*
Child's Date of Birth*

MonthDayYear
Date
My child has a*

Suspected AllergyFood Intolerance
Indicate which food or food type your child has suspected allergy / food intolerance*
I suspect / am concerned that my child may be allergic for the following reasons:*

No Previous ExposureFamily HistoryPrevious ReactionOther
If "Previous Reaction" was selected above, please explain below.*
If "Other" was selected above, please explain below.*
I understand that Just 4 Kids requires the most up to date information regarding my child's suspected allergy or food intolerance. I also understand that for the safety of my child, my child’s allergy information will be posted in the classroom and the kitchen.
Parent / Guardian Email*
You will receive a copy of this PDF you just filled out thru this email address.
Date*

MonthDayYear
Date
Parent / Guardian Signature*

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SUSPECTED ALLERGY & FOOD INTOLERANCE FORM