D-Bar-A Dietary Restriction Notification Card printable pdf download

Michigan Crossroads Council

D-bar-A Scout Ranch

Dietary Restrictions

D-bar-A Dietary Restriction Notification Card

We must receive this card 45 days prior to your time at D-bar-A in order to make the necessary substitutions. If this card

is not received within the specified time, we cannot guarantee the substitutions. We will do our best to accommodate

your needs, but for certain severe allergies or for a person with an allergy to more than 2 types of food, we may ask you

to bring your own food. Please bring your own medication (ex. Epipen).

Please fill out ONE CARD PER INDIVIDUAL with a dietary restriction. ALL FIELDS ARE REQUIRED.

Camp Attending (circle one)

Cub Scout

Boy Scout

Trail to Eagle

Other

Dates Attending: ________________________

Unit Type: _____________

Unit Number: _____________

Name of person with restriction:_____________________________________________

Phone # and Email:_____________________________________________________________________

(of parent if youth or individual if adult)

Restriction type:__________________________________________

(i.e. peanut allergy, vegetarian etc.)

Please circle all that apply: If an allergy is it by? Ingestion

Contact

Airborne

Other _________________________________

Severity of Allergy (i.e. anaphylactic):_______________________________________________________

Is Allergy controlled or treated by medication? _______________

If so, will individual have this medication at camp? _________ What is the medication?______________

Symptoms Experienced (i.e. vomiting):______________________________________________________

Substitution Ideas:______________________________________________________________________

Any other information you think would be useful to the food service staff at D-bar-A:

_____________________________________________________________________________________

Office Use Only:

Contacted Date: ________________

Initials: _________________

Accommodations Made: _________

Brining Own Food: ________

Fax this form to 810-245-2250 or Email form to

3/24/2015 – DW

FS-601

D-Bar-A Dietary Restriction Notification Card