Student Food Allergy/modification Information Form


Student Food Allergy/Modification
Information Form
Student name
School Attends
Parent name
Home Address
Phone Number
Email address
Grade & teacher
Lunch Lady
Allergy Information
(please check box)
Other Allergies:
Type of Reaction:
Epi-pen used?
Yes / No
Meal Modifications Required:
Substitution Meal:
My Child is Diabetic:
Yes / No
Diet Controlled: Yes/ No
Yes/No Require copy of Nutrition Chart: Yes/No
My Child is Gluten Free:
Yes / No
Parent Signature: ___________________________________________ Date: _____________________________________
Please Note: that while your Lunch Lady strives to ensure that lunches are allergen free, Lunch Lady cannot guarantee the total
absence of allergens and that cross-contamination will not occur at some stage in the food handling and/or delivery process. If
your child has an allergy, please inform and educate your Lunch Lady and your school about your child’s allergy action plan and
any emergency treatments that may be required in the event of an allergic reaction.
For assistance or additional information please contact:
Local Lunch Lady:
Lunch Lady Head Office: 905-660-5994 or toll free 1-800-603-6656


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Parent category: Miscellaneous