Food Allergy/Restrictive Diet Form
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.
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?
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.
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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
2007 1.Niijima, K. ・Enta, K.・Hori, H.・Sashihara, S.・Mizoue, T.・Morimoto, Y.: The usefulness of sleep apnea syndrome screening using a portable pulse oximeter in the workplace J Occupat Health 49(1)：1 - 8 2007． 1． 2.Yoshimura, R. ・Shinkai, K.・Ueda, N.・Nakamura, J.: Valproic acid improves psychotic agitation without influencing plasma risperidone levels in schizophrenic p