Vanderbilt Bill Wilkerson Center Centro Bill Wilkerson de Vanderbilt National Center for Childhood Deafness and Family Communication (NCCDFC) Centro Nacional para la Sordera Infantil y Comunicación Familiar Mama Lere Hearing School at Vanderbilt Escuela de Audición “Mama Lere” en Vanderbilt Medical Center East, South Tower (Centro Médico Este, Torre Sur) 1215 21st Avenue South, Room (Sala) 6209 Nashville, Tennessee 37232-8105 Teléfono: (615) 936-5262 Fax: (615) 936-1225 FORMA DE ALERTA DE ALERGIAS / ALLERGY ALERT FORM Para asegurar el bienestar de su niño, por favor complete esta forma referente a sus alergias. Si su niño no tiene alergias, favor de indicarlo. Nombre del niño: Anote las alergias conocidas a ALIMENTOS:

¿Cuál es la reacción?

Anote otras ALERGIAS:

¿Cuál es la reacción?

Información médica/instrucciones a seguir en el evento de una reacción:

Firma de los Padres/Tutor White-Student Chart Form 0001 Rv.10/08/07

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Vanderbilt Bill Wilkerson Center National Center for Childhood Deafness and Family Communication (NCCDFC) Mama Lere Hearing School at Vanderbilt Medical Center East, South Tower 1215 21st Avenue South, Room 6209 Nashville, Tennessee 37232-8105 Phone: (615) 936-5262 Fax: (615) 936-1225 ALLERGY ALERT FORM Please complete the form provided to ensure your child’s safety regarding any and all allergies. If your child has no known allergies, please indicate that as well. Child’s Name List known FOOD ALLERGIES:

What is the reaction?

List other ALLERGIES:

What is the reaction?

Medical information/instructions in the event of a reaction:

Signature of Parent/Guardian White-Student Chart Form 0001 Rv.10/08/07

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