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SCHOOL NOTE REQUEST FORM
Please Use a Separate Form For Each Child
Today's Date:
MM slash DD slash YYYY
Child’s First & Last Name:
(Required)
Child’s DOB:
(Required)
Parent/Guardian First & Last Name:
(Required)
Parent/Guardian Cell Phone Number (in case of any questions):
(Required)
Parent/Guardian e-mail address:
(Required)
Child’s Current Weight: (Required for antihistamine and epinephrine)
Reason for Medication (check all that apply):
(Required)
Asthma
Angioedema/Urticaria
Food Allergy
FPIES
Other
Reason for Medication(Other):
Type of Note Needed (check all that apply):
(Required)
Daycare/Preschool (NYS forms)
School (K-12) 2025-26 school year
Before or After Care Program (NYS forms)
Day Summer Camp
Overnight Summer Camp
Camp Start Date:
(Required)
Does your child have a FollowMyHealth account?
(Required)
Yes
No (We will send an invite to the email address above)
Name
This field is for validation purposes and should be left unchanged.