Food Allergy Notification Form

Dear Parents,

LTS is required by law to request, at the time of enrollment, that the parent or guardian of each student attending LTS disclose the student’s food allergies. This form will satisfy this requirement.

This form allows you to disclose whether your child has a food allergy or severe food allergy that you believe should be disclosed in order for LTS to take necessary precautions for your child’s safety.

“Severe food allergy” means a dangerous or life-threatening reaction of the human boy to a food-borne allergen introduced by inhalation, ingestion, or skin contact that requires immediate medical attention.

Please list any foods to which your child is allergic or severely allergic, as well as the nature of your child’s allergic reaction to the food. LTS will contact you for a note from your physician if your child has food allergies. Your child must have an EpiPen prescribed to help in the event of an emergency.

Food

Nature of allergic reaction to the food

LTS will maintain the confidentiality of this form and the information provided above, and may disclose the information to teachers, school counselors, school nurses, and other appropriate school personnel only within the limitations of the Family Educational Rights and Privacy Act and Board of Directors policy. LTS will maintain this form as part of your child’s student record.

Student’s Name: __________________________________ Date of Birth: _________________

Grade: _____ Parent’s/Guardian’s Phone: ___________________________________

Parent’s/Guardian’s Name: _______________________________________________________

Parent’s/Guardian’s Signature Date

For official use only. Date form received by Legacy Traditional Schools - Texas: _____________________