Food Allergies and Restrictions form | Whitney Child Centre

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Food Allergies and Restrictions form

Whitney Child Centre Food Allergies and Restrictions form
Child's Name
Parent's Name
Classroom
Anaphylactic Allergy*
- Yes
- No
Please itemize any of the restricted food items in areas below. If not applicable, please enter N/A.
Food allergy sensitivity
Cultural Restriction(s)
Health Issue/Food Restriction(s)
Vegetarian
Parent/Legal Guardian Signature
Date

DD
MM
YYYY

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