If your child has food-related allergies, it is required that the family discusses the allergies with our cook and your child’s classroom teacher prior to their first day of enrollment.
If the food allergy is not life threatening, the parent may substitute a like item for the allergy food. The family must also provide substitutions for religious or cultural reasons. You must substitute foods from a like category such as a protein for a protein item, a grain product for a grain product and so on. All foods and beverages brought from home must be labeled with the child’s full name, date and classroom. As required by the USDA Food Program, if the allergy is life threatening, Learning Ladder will substitute similar menu items for substantiated life threatening food allergies only if a Child Health Report, signed by a physician that clearly defines and details the child’s restrictions is on file. It is your responsibility to keep the teacher and cook up to date with any changes by filling out a new restrictive diet form or inform us in writing if your child is no longer allergic to a food. A child with a life threatening food allergy is required to have an Epi-pen and Benadryl in the center at all times with a current medication authorization form signed by the parent . It is the parent’s responsibility to monitor the expiration date of their child’s Epi-pen and replace as needed.
I have read and understand the information stated above. I will provide any and all substitute foods when necessary and will update this form as needed or notify Learning Ladder in writing if my child no longer requires a restrictive diet. All information provided by me on the back side will be considered true and accurate to the best of my knowledge. Parent Please fill out back side of form
Please complete this form with as much detail as possible.
What specific food(s) is your child allergic to?
Is this food life threatening? If Yes, an Epi-Pen and Benadryl must be kept at Learning Ladder along with a current Authorization to Administer Medication form What food will you be bringing in to supplement? Example: Soymilk
Are you planning to introduce any new foods? Please explain in detail
Would you like to meet with the cook on a regular basis to read labels or discuss menus?
What are the signs of an allergic reaction?
What do you want us to do if we see signs of a reaction? (An Authorization to Administer Medication form must be on file to administer any medications)
I hereby declare that all information provided is complete and accurate to the best of my knowledge. Any changes to this or any other form will be provided in writing. Parent Name Page 2 of 2
Holston Conference Camp and Retreat Ministries Staff Name (Print) In an emergency situation, use these contacts as necessary: Second Parent/Guardian: Pre-Authorization Phone # if required ( ) Authorization – Must be signed. In signing this authorization, I acknowledge that I have read the event description and am aware that the activities associated with this event entail certai
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