Food Allergy Form
Student's Parent or Guardian Name
Relationship to Student
Parent's Contact No. (Work)
Parent's Contact No. (Home)
- Tree Nuts
- Citric acid
- Fava Beans
Other special diet needs or restrictions (i.e., Diabetes, IBS, other)
Please answer the following questions to better help us with your needs:
What are the preferred food substitutions, if any? (e.g., soy butter for peanut butter, gluten-free bread, soy milk, etc):
What types of contact will cause a reaction?
Does the Student understand the food allergy and what needs to be done to manage it?
By signing this I am certifying I understand the disclaimers contained in this form and I verify the information provided is true and correct.