D-Bar-A Dietary Restriction Notification Card

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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

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