Night Drop Off Form Child Information:Child’s Name: DOB : MM slash DD slash YYYY Nickname: Gender Male Female Primary Home Address:Parent/Guardian Information:Parent 1/Guardian 1 Name: E-mail Address: Home# CellPhone#: Text Messaging: (Please initial)(Required) I hereby permit Young Minds in Motion to text message my cell phone number only when important announcements must be communicated, such as emergencies, school closing, and other events that will affect my child’s care. Food Allergy PlanAllergy Info My child does NOT have a food allergy that requires restrictions or medications. My child does NOT have any allergies. 1. Name of Allergen (pea nuts, eggs, shellfish, etc.) Previous reactions (rash, lip swelling, nausea/ vomiting, difficulty breathing, anaphylaxis;etc.): Dietary Restriction Complete avoidance Avoid in these specific forms: Other recommendations: If other recommendations is checked:Emergency Treatment, if required * Epinephrine Benadryl Other If other treatment is checked: Δ
