Dunes Learning Center Dietary Restriction Form
Complete this form ONLY if your child has a dietary restriction. If your child does not have any dietary restrictions, you may ignore this form. Dietary Restrictions include food allergies, diabetes, vegan diet, vegetarian diet or religious requirements.

WE MUST RECEIVE THIS FORM AT LEAST 3 WEEKS PRIOR TO YOUR ARRIVAL in order to adjust menus to accommodate your special dietary need.

If the restriction is for a medical reason, please include a copy of a physician’s statement or diet order.  Copies of existing letters on file with your school nurse’s office are acceptable. If you have questions or concerns, please contact the Food Service Director at 219-395-9555 or email at dbrown@duneslearningcenter.org.
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Participant Name *
School Name *
Arrival Date *
MM
/
DD
/
YYYY
Dietary Restriction *
Please describe the dietary restriction
Reaction to Restricted Food
If the restriction is for medical reasons, please describe the reaction
Treatment
If the restriction is for medical reasons, please describe the treatment
Foods to Omit *
Please be specific
Foods to Substitute
Parent or Guardian Name *
Parent or Guardian Home Phone Number
Parent or Guardian Mobile Phone Number *
Parent or Guardian E-mail Address
Submit
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This form was created inside of Dunes Learning Center.