The Food Allergy & Anaphylaxis Network

Education. Advocacy. Research. Awareness.

Here's how the program works:

School Representatives (such as the principal or school nurse) from elementary, middle, and high schools can nominate their schools to receive a free copy of the School Food Allergy Program.

To nominate your school, complete the form below. FAAN will process your nomination and ship the program directly to the school. Shipments will continue until supplies are exhausted.

School Information

Please use one form per school
Items with an asterisk (*) are required.

I would like a free copy of the School Food Allergy Program in the following format:

DVD:     VHS:

School Principal Information

*First Name:

*Last Name:

School Nurse Information

First Name:

Last Name:

*Telephone:

Days/times available at that number

About Your School

*School Name:

*Address 1:

Address 2:

*City:

*State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

*Zip:

E-mail:

Fax:

How many food-allergic students in your school in:

School Year 2003-04:

School Year 2004-05:

School Year 2005-06:

*Your School Is:

Public:     Private:

And...

Elementary

Middle School

High School

Other  

In your district how many schools does each nurse cover?

One   Two   Three   Four   Five or More

About Your State

Is the school nurse allowed to administer epinephrine?
    Yes      No

Is the student allowed to carry his or her own epinephrine?
    Yes      No

Is the school nurse allowed to train other school personnel to administer epinephrine in his or her absence?
    Yes      No

  If yes, which personnel?
    Principals     Teachers     Bus Drivers     Coaches    Food Service Workers
   Other