Allergy Forms – Anshei Lubavitch

(Only to be filled out for children who have allergies)

Please attach a picture of your child
Child’s Name
First Last
Date of birth
Date Format: MM slash DD slash YYYY
Allergies
Instructions in case of accidental exposure to allergen:
Please make sure that we have all necessary items to deal with an emergency.
Emergency Contacts
Name Phone
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There are no Contacts.
Maximum number of contacts reached.
(Please provide at least 3 Emergency Contact)
Medical Authorization*
I hereby request and authorize the Anshei Lubavitch Day Care Center (ALDC) personnel to administer medication to my child as directed by my physician. I agree to release, indemnify and hold harmless ALDC and any of its officers, staff members, or agents from lawsuit, claim demand, or other action against them for administering medication to this student.

ALDC will make all reasonable efforts to give medication in a timely fashion, but the final responsibility for administration of medication rests with the parents. Please note that we require that all medication be in the original prescription bottle or packaging.
- I agree
Prescribing Physician’s Name:*
First Last
Prescribing Physician’s Phone Number:*
Parent Name*
First Last
Home Phone Number*
Work Phone Number*
Cell Phone Number*
Signature*
Date*
Date Format: MM slash DD slash YYYY

Name	Phone
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There are no Contacts.