Individual Student Special Requirement Authorization

Individual Student Special Requirement Authorization
Brason Academy Montessori School strives to provide a positive and healthy school environment. Included in its programming, the school provides all snacks, beverages, and a warm, catered lunch on a daily basis.

If for any reasons, your child is prohibited from participating in any of the meals or beverages offered by the school, for either religious, philosophical, personal family food choices, and/or allergies, please fill out in completion the form below.
Child's full name

First NameLast Name
Date of birth

MonthDayYear
Class
Program

CasaToddler
Food Related Exclusion

ReligiousAllergyPersonalPhilosophical
Comments required
Are there any health concerns?
Is there any medication required? If yes, please describe
Instructions that you would like the staff to follow if there is a complication (example: parents are to send in food replacement)
Parent Action Plan in the case of a complication
Parent's full name

First NameLast Name
Parent signature

Clear
Date Effective

MonthDayYear
Duration:
Should be Empty: