Food Allergy Advisory Form

Food Allergy Advisory Form

This form submits to the director of Dining Services, the executive chef at Dining Services, the nutritionist of Dining Services, and the dietician in Health Services.

"*" indicates required fields

MM slash DD slash YYYY
Your name*
A copy of this form will be automatically CC'ed to you.
xxx-xxx-xxxx
Epi-pen required?
If yes, do you carry an epi-pen with you at all times?
Permission to share information*
I give Health Services and Dining Services permission to share information about my food allergy.