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Ascension School - Food Allergy Packet

Please complete the form below. Required fields marked with an asterisk *

Dear Parent,

Attached is the 2026-2027 food allergy packet to complete and return for the upcoming school year. It is important that I have these on file by the first day of school, along with the medication(s) needed in case of an allergic reaction. Please remember that all Epi-pens and antihistamine medications must be in their original containers labeled with the child’s name, and that the medication will not expire during the school year. All medications (including over-the-counter antihistamines) need a signed physician’s order. Medication orders may be faxed to +1-636-532-6502. Should you have any questions, please feel free to call the school office.

Since your child has a food allergy, we are asking you to provide a picture of your child, either digitally to [email protected], provided to the front office. This picture will be placed in a private location in the cafeteria, for the food staff and teachers to use to help identify students.

Thank you,

Gretchen Kirsch, RN, BSN

I give permission to Ascension School to post a picture of my child (in a private location) for the use of identifying him/her in the lunch room.*

Answer required for "I give permission to Ascension School to post a picture of my child (in a private location) for the use of identifying him/her in the lunch room."

Yes

Parent Name:*

Answer required for "Parent Name:"

Student Name:*

Answer required for "Student Name:"

Student Grade & Homeroom*

Answer required for "Student Grade & Homeroom"

My child is allergic to:*

Answer required for "My child is allergic to:"

Please describe your child's allergic reaction:*

Answer required for "Please describe your child's allergic reaction:"

Please list the medications your child receives for the allergic reaction including the dose and frequency of administration:*

Answer required for "Please list the medications your child receives for the allergic reaction including the dose and frequency of administration:"

I will leave the following medications with the school nurse in the event my child has an allergic reaction at school:

Medication 1:

Answer required for "Medication 1:"

Medication 2:

Answer required for "Medication 2:"

Medication 3:

Answer required for "Medication 3:"

Medication 4:

Answer required for "Medication 4:"

Does your child know to avoid these foods/ substances?*

Answer required for "Does your child know to avoid these foods/ substances?"

Yes

Are you aware of any products that contain the substance your child is allergic to? (i.e. some clays contain nut oil)*

Answer required for "Are you aware of any products that contain the substance your child is allergic to? (i.e. some clays contain nut oil)"

Is there any other information school personnel should be aware of?*

Answer required for "Is there any other information school personnel should be aware of?"

*All medications (including over-the-counter antihistamines) need a signed physician's order.

The Food and Allergy Anaphylaxis Emergency Care Plan can be found here.

Please print, fill out, and return to the school nurse bu August 11, 2026.

Parent/ Guardian Signature:*

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"