Dietary Restrictions/Allergen Form

Academic Year(s)

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(ex: 2024, 2024-2026)

Where will you be residing?

On Campus

Off Campus

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First Name

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Last Name

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Phone (cell/home)

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(xxx) xxx-xxxx

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I have a severe/life threatening allergy that is medically diagnosed and requires a need for an epi-pen or similar safety measures.

I am allergic to peanuts

I am allergic to wheat

I am allergic to dairy

I am allergic to shellfish

I am allergic to tree nuts

I am allergic to soy

I am allergic to sesame

I am allergic to egg

I am allergic to fish

I am lactose intolerant

I have Celiac disease

Other Allergens (Please List)

I understand that salad bars, fruit bars, bakery, "create your own" stations and similar setups, by its very nature, carries with it certain inherent ingredient cross contact risks that cannot be eliminated, regardless of the care taken, because of other customer interactions and ingredient substitutions. All menus/ program/websites/marketing outlets/signs that contain nutritional symbols and ingredient information are provided for a reference only. Items may contain allergen ingredients without prior notice due to manufacturer or unit substitutions. If there are any questions regarding specific menu item ingredient(s), one must consult the onsite manager to ensure that the particular menu item is free of said allergens before consuming. I acknowledge that I have read, understood, and agree with the information presented on this form.

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Dietary Restrictions/Allergen Form

Dietary Restrictions & Allergens

Self Report Form

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