Allergy, Intolerance, or Sensitivity Information Form (no medication required)

Child's Name

First

Last

What Tomorrow's Topkids Clubhouse is your child enrolled in?

At Tomorrow's Topkids, safety is our number one priority. We need your help to make sure your child's experience is both fun and safe. Detailed information for all allergies, intolerances, or sensitivities listed on a registration form are required to be kept on file. This form is for allergies, intolerances, or sensitivities that do not require medication. Please complete a separate form for each allergy, intolerance, or sensitivity listed on your child's registration form.

I understand that this form must be completed in full.

I understand that medication including, but not limited to: Benadryl, bug bite relief, Tylenol, Gravol, etc. cannot be on site without additional forms signed by a physician.

Yes, I understand.

My child has an:

Allergy
Intolerance
Sensitivity

My child does not require any medication to be administered for this Allergy, Intolerance, or Sensitivity.

Correct, my child does not require any medication to be administered.
Incorrect, please send me the forms required to be completed by a physician for my child's medication.

My child is allergic, intolerant, or sensitive to:

Please describe IN DETAIL, your child's allergic, intolerant, or sensitivity reaction to INGESTION:

Please describe IN DETAIL, your child's allergic, intolerant, or sensitivity reaction to TOUCH:

Please describe IN DETAIL, your child's allergic, intolerant, or sensitivity reaction to SMELL:

EMERGENCY PLAN: Please describe in detail the steps that you would like our staff to follow should your child have a reaction. This section cannot be left blank. Please note: if any medication (such as Benadryl, bug bit relief, Tylenol, Gravol, etc.) is listed in your emergency plan, additional forms will be required to be completed by a physician.

Parent/Guardian Name

First

Last

Parent/Guardian Phone Number

Parent/Guardian Email

Parent/Guardian Electronic Signature (please type)

bit each Topkids,

I understand checking this box constitutes a legal signature that I acknowledge and agree to the above terms.

Yes, I understand.

Date Completed (dd-mm-yyyy)