Soy Allergy Pre-Packaged Snack Declaration Form
Name of Student:
Grade/Class:
Parent/Guardian Name:
Contact Number:
Pre-Packaged Snack Brand & Name:
Ingredients List (as shown on package):
Does the snack state it contains soy, may contain soy, or is processed in a facility with soy?
Yes
No
Other Allergen Information:
Declaration (Parent/Guardian Signature):
Date: