Dietary Accommodation Request Form - New Birth Of Freedom Council

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DIETARY ACCOMMODATION REQUEST FORM
Please complete all fields on this form.
CAMP DETAILS:
(Please select)
Cub Scout Summer Camp
Webelos Summer Camp
Boy Scout Summer Camp @ Camp Tuckahoe
Boy Scout Summer Camp @ Hidden Valley
Camp Week #: ___________
Dates in Camp: ____________________________________
CAMPER’S INFO:
Pack or Troop #
Pack / Troop #: ___________ Council: _______________________ District: _______________________
(Please select)
Camper’s Full Name: _____________________________________________________________________
Parent’s Name: _________________________________________________________________________
(If Camper is under 18)
Home Phone #: ______________________________
Cell Phone #: _____________________________
E-mail Address: ________________________________________________________________________
DIETARY CONSIDERATIONS:
Camper has an allergy or other medical condition diagnosed by a physician and is documented on his/her
BSA Annual Health Form.
Gluten
Dairy
Egg
Peanut
Red Dye
Vegetarian
Other: _______________________
How severe is the allergy?
MODERATE
STONG
SEVERE
Camper does not have a medical condition but requests a dietary accommodation.
Please describe _______________________________________________________________________
PLEASE SPECIFY FOODS TO BE AVOIDED AND SUBSTITUTED.
(Attach additional sheets as needed.)
Foods to Be Avoided
Recommended Alternatives
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