Student Food Allergy/modification Information Form printable pdf download

Student Food Allergy/modification Information Form

Student Food Allergy/Modification

Information Form

Date

Student name

School Attends

Parent name

Home Address

Phone Number

Email address

Grade & teacher

Lunch Lady

Allergy Information

(please check box)

Allergy

Sensitivity

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

Insulin:

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 Email:allergymanagement@thelunchlady.ca

Student Food Allergy/modification Information Form