* = Required Information

My child, is allergic to the following food items:

In the event of accidental contact or ingestion, I authorize to administer emergency medical treatment for my child, by giving him/her a dose of: . Directions for administering the above medication from my child's physician can be found attached to this form.


My child, , has the following dietary restrictions (i.e is NOT allowed to eat dairy products, can ONLY eat soft foods, etc.):

(Optional) I want my child, , to be fed the following items as substitutes for those restricted:

I will provide and label the food listed above for my child to be served while in the provider's care.

I understand that I assume all financial responsibility for any treatment or injuries sustained by my child while she/he is in child care.

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