Child care and preschool center directors in Illinois can nominate their schools to receive a free copy of FAAN’s Child Care and Preschool Guide to Managing Food Allergies program.
Here's how to nominate your center:
The Food Allergy & Anaphylaxis Network CCP 11781 Lee Jackson Hwy., Suite 160 Fairfax, VA 22033 Fax: (703) 691-2713
Please use one form per center.
Completed, signed forms will be processed by FAAN, and the free programs will be shipped directly to the center. Although the distribution is currently limited to Illinois, we are seeking funding to make the program available nationwide.
Shipments will continue until supplies are exhausted. All forms must be signed and filled out completely or they will not be processed.
1. Center Identification (enter either SSN or FEIN, no dashes): SSN: or FEIN:
2. Center Director’s Name: First: Last:
3. Center Name:
Address:
City:
State:
IL
Zip:
-
4. Center Phone: Fax: E-mail:
5. Type of Center: Family Child Care (in provider’s own home) Child Care Center (not in provider’s home)
6. Head Start Program? Yes No
7. State-Funded Pre-K Program? Yes No
8. Ages Cared For (enter years and months) Youngest: Years Months Oldest: Years Months
9. Licensed Capacity If Family Care: What is your total capactiy?: children If Child Care Center: What is your total capacity?: children
10. How many children with food allergy were enrolled in these years? 2004-05 2005-06 2006-07
11. What is the title of the person primarily responsible for the health care of the children in your center?
12. Which format of video do you prefer? DVD VHS
The child care or preschool director must complete this section and sign below.
As director of the nominated center, I (print your name) _____________________________ will accept the gift of the Food Allergy & Anaphylaxis Network’s Child Care and Preschool Guide to Managing Food Allergies. I agree to use it to help the children with food allergies in my center manage their allergies.
Signature and Date
___________________________________________
Title