Food Allergy Info & Release Form
I give permission for the release of the information below, which may attest to the existence of a severe and chronic medical condition, to be shared with appropriate personnel in the Department of Dining Services (including but not limited to Cooks, Dining Service Aides, Purchasing Agent) as well as personnel in the Department of Student Health Services or Student Counseling Services. *
This information will be sent directly to Dining Services. You will contacted in the very near future.
Last Name: *
Your answer
First Name: *
Your answer
Email Address: *
Your answer
Cell Phone:
Your answer
I have the following food allergies: *
Required
Additional information about your allergy or intolerance:
Your answer
Food / Ingredients Avoided:
Your answer
Food / Ingredients Included in Diet:
Your answer
Where on campus do you live? *
Your answer
What locations on campus do you most often dine? *
Your answer
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