Little Hoku Montessori Academy > Admissions > Forms > Special Care Plan for Allergies [] 1 Step 1 Student Information Child's NameEnter Full Nameface Nicknamefavorite_border Date of Birthdate_range Emergency Contact Information Parent/Guardian Name Phone NumberBest phone to reach you in case of emergencylocal_phone Emailemail Primary Healthcare Provider Physician NameEnter Full Name PhoneEnter the best phone number to contact you atcall Facility/Clinic Name0 / Health Insurance Information Insurance Company Policy HolderEnter policy holder's name Policy Holder Date of Birthdate_range Insurance ID Group Number Group Name Health/Allergy Information Description of AllergiesPlease enter all relevant allergies0 / Description what signs/or symptom look like?Please enter all relevant information0 / Description known triggersPlease enter all relevant information0 / Description of treatmentPlease enter all relevant information0 / Description side effects: i.e.: No peanut products allowedPlease enter all relevant information0 / Signature Parent/Guardian Signature(Sign Here)Clear Signature Submit Admissions Application keyboard_arrow_leftPrevious Nextkeyboard_arrow_right