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.
I have the following food allergies:
Wheat Gluten (Gluten Intolerance)
Wheat Gluten (CELIAC Disease, Diagnosed)
Additional information about your allergy or intolerance:
Food / Ingredients Avoided:
Food / Ingredients Included in Diet:
Where on campus do you live?
What locations on campus do you most often dine?
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