Holiday Lake 4-H Educational Center - Dietary Needs & Allergen Accommodations Form
If you have any Dietary Needs, Food Allergies, or Restrictions, please fill out the form below as accurately as possible so that we can best accommodate you during your Events. This form should be completed for each event you will be attending.
Sign in to Google to save your progress. Learn more
Participant Name: *
(First/Last)
If under 18, Parent/Guardian Name: *
(First/Last)
In case we have questions for you, please provide your Phone Number: *
(000) 000-0000
In case we have questions for you, please provide your E-mail: *
JohnnyApple@Example.com
Name of Event: *
Event Start Date: *
MM
/
DD
/
YYYY
Please select all dietary restrictions and/or allergies that affect you: *
(Select all that apply)
Required
If "Other", Please describe below as accurately as possible and we will contact you regarding the best way to accommodate you. 
Please explain the severity of your dietary needs or allergies. 
**For example, describe the sensitivity level to your restriction or allergen (airborne, cross-contamination, etc.). 
- If Lactose Intolerant (Limited Dairy Intake), please specify tolerance for dairy products (milk, butter, cheeses, cooked dairy, etc.). 
- If Gluten Free (Limited Gluten Intake), please specify tolerance for gluten products (bread, breading, wheat inclusion, etc.).
 *
Please indicate your preference for accommodations needed for your diet: 
***NOTE: We will make all reasonable efforts to accommodate you, however, there are instances where we may not be able to provide alternatives for your needs.*
 *
Required
Please indicate whether you'd like to be contacted with information regarding the event menu and available substitutes specific to your needs: *
Required
Please provide any additional information or requests that you'd like to communicate to the Kitchen Staff. Thank you.
NOTICE TO ALL FORM RESPONDENTS: 
(Read Carefully)
This form is not used in any other way but to collect as much information possible regarding your Dietary Needs, Food Allergies, or Restrictions in order for our Kitchen Staff at Holiday Lake 4-H Educational Center to best provide substitutions for the meals that will be served during your time here. This form should be completed for each Event that you register to attend at Holiday Lake 4-H Educational Center.

There are, in some cases, such needs or allergies that we are UNABLE provide substitutions for. 
Some of these include but are not limited to:
- Vegan 
- Diabetic/Low Sugar
- Low Sodium/Low Salt
- Pescetarian (Limited Accomodations)

Once this form has been completed, notify your Group/Event Leader that this form specifically was completed. 
Once you arrive at the event and the meals commence, please notify a member of the Kitchen Staff at the START OF EACH MEAL your name and listed restriction. The Kitchen Staff will obtain your specific substitution for the attended meal and provide it to you as quickly as possible. 

If you have any questions regarding the Menu for your Group/Event, please direct them to your Group/Event Leader. If you have any further questions regarding the substitutions that will be provided to you during your time here, please notify your Group/Event Leader to let us know and the Food Service Manager or Kitchen Operations Manager will get in touch with you as soon as possible. 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Virginia Tech.

Does this form look suspicious? Report

Google Forms