• Al-Huda Islamic Center - Muslim Community of Ithaca and the Finger Lakes
  • Open for Daily and Friday Prayers Jumma @ 1:15PM

CIS Input Form

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CIS Student Allergy Questionnaire Input Form
Fields marked with an * are required
 
Date of Birth *
Has your child being diagnosed with allergies/anaphylactic reactions?
 
Does your child react to skin contact with the allergen?
Does your child react to swallowing the allergen?
Will your child immediately tell an adult if exposed to an allergen?
Does your child know what to avoid?
Does your child ask about ingredients in food?
Does your child tell others about his/her allergies?
 
Can your child give his/her own injection with an EpiPen if prescribed by their Health Care provider?
 
 
 
 
 
Does this child wear an identifying tag or bracelet alerting others to the Allergy?
 



Parent Information
 
 
Date
 
 

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