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980-699-8047
administrator@5and2traininginstitute.org
101 Break the Cycle Drive, Polkton, NC 28135
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101 Break the Cycle Drive, Polkton, NC 28135
980-699-8047
administrator@5and2traininginstitute.org
5&2 Training Institute Food Allergies and Medical Conditions Form
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Please enable JavaScript in your browser to complete this form.
STUDENT INFORMATION
Name
*
First
Last
Date of birth
*
MM/DD/YYYY
Emergency Contact Name:
*
Emergency Contact Numbers
*
Emergency Contact Email
*
Relationship to Student
*
ALLERGIES
Do You have any Food Allergies?
Yes
No
If Yes, List all Food Allergies.
Reaction Severity
Mild
Moderate
Severe
Symptoms of Allergic Reaction (check all that apply)
Hives
Difficulty Breathing
Swelling
Vomiting
Others
Specify If any other reactions:
Is epinephrine (e.g., EpiPen) required for severe reactions?
Yes
No
ALLERGY MEDICATION INFORMATION
Are you taking any medications related to your food allergies?
Yes
No
1. Name of Allergy Medication
Dosage
Frequency
Daily
Weekly
Monthly
2. Name of Allergy Medication
Dosage
Frequency
Daily
Weekly
Monthly
Do you carry the medications with you at all times?
Yes
No
Have you ever experienced an anaphylactic reaction?
Yes
No
If yes, please describe the incident briefly:
PRESENT MEDICAL CONDITION INFORMATION
Name of Medical Condition(s)
1. Name of Current Medication
Dosage
Frequency
Daily
Weekly
Monthly
2. Name of Current Medication
Dosage
Frequency
Daily
Weekly
Monthly
3. Name of Current Medication
Dosage
Frequency
Daily
Weekly
Monthly
Do You have any Medication allergies?
Yes
No
If Yes, List Names of all Medications you are allergic to:
other Food the
AUTHORIZATION AND ACKNOWLEDGEMENT
By completing this form, I authorize 5&2 Training Institute to share my food allergy and medication information with dining staff, residential life staff, and other necessary personnel to ensure my safety. I understand it is my responsibility to provide updated information as necessary.
Signature*
Type Your Name
Date Input
*
MM/DD/YYYY
Submit
