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500 Cumberland Road, Pittsburgh PA 15237 Phone: (412)-635-4101 Fax: (412)-635-4115 |
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THIS FORM MUST BE SUBMITTED AT LEAST 48 HOURS PRIOR TO THE DATE OF THE TREAT Student Name _________________________Homeroom/section____ Telephone Number(s): ______________________________________ Date of Request: _____________________________ Date of Treat: _______________________________ List of ingredients: __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ List of Allergens: __________________________________________ *Make sure to check if processed on shared equipment or in a facility that also processes nuts or wheat. (This information is located under the list of ingredients). NO TREATS WILL BE PERMITTED IN THE CLASSROOM UNLESS APPROVED BY THE NURSE AND 48 HOURS NOTICE HAS BEEN GIVEN. ______Approved by Nurse and returned to teacher on ______ |
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