Summer Allergies & Dietary Needs Form

Thank you for taking the time to thoroughly complete the Summer Allergies & Dietary Needs Form. Our campus dietitian, Olga Goumas, will work with you to ensure that you/ your student will have a safe dining experience throughout their program's stay.

Please complete this form only if you have specific medical or religious dining needs.

Please Note:

Participants and guests with severe food allergies are expected to carry their own medications at all times (e.g Benadryl or Epipen) and know how to use them in the rare case of a reaction.

If it is not possible to accommodate a medically based dietary requirement, such as a food allergy, we will notify you immediately so alternative arrangements can be made.

Although we will take food preferences into consideration, we may not always be able to accommodate these requests.
Name of Participant Name of Participant First Last
Age of Participant (if minor under 18)
Your Name (if different than participant) Your Name (if different than participant) First Last
Your Relationship to Participant
Best Phone Number for follow-up Best Phone Number for follow-up - ### - ### ####
Email Address to contact with follow-up
Name of Summer Program
If your group is not listed, please provide your program name:
Arrival Date Arrival Date / MM / DD YYYY
Departure Date Departure Date / MM / DD YYYY
Preferences such as vegetarian or vegan meals are easily accommodated in all dining commons. Please indicate if you are allergic to any of the following foods:

Preferences such as vegetarian or vegan meals are easily accommodated in all dining commons. Please indicate if you are allergic to any of the following foods: Dairy Egg Fish Gluten (Celiac Disease) Peanut Sesame Shellfish Soybean Tree Nuts Wheat Other Other
Please list any religious dining needs such as Kosher or Halal.
Please provide additional details on the participant's food allergies, any medical conditions (e.g. Celiac Disease, Diabetes, IBS) or religious dining needs that may involve food restrictions.
Other dietary restrictions/intolerances:
Additional Resources

Our staff will be in contact to confirm that your request has been received and to outline further instructions for safe dining.
Comments/Questions:

Summer Allergies & Dietary Needs Form

Summer Allergies & Dietary Needs Form

Please Note:

Additional Resources