EmailMe Form - Food Allergy/Special Dietary Needs

Child's Name *

First Last

Camp Start Date *

MM / DD / YYYY

Camp End Date *

MM / DD / YYYY

Does your child have a food allergy? *

Yes

No

If yes, please be sure to list all food allergies that your child has. Please be as specific as possible.

Does your child have any food intolerances? *

Yes

No

If yes, please list the intolerance, the exact foods they cannot tolerate and any foods that you substitute for this intolerance (example: lactose intolerance, uses Lactaid, but can eat cheese, yogurt, ice cream

What type of reaction does your child have to the above items (allergy and/or intolerance)? *

Is the food allergy diagnosed by a physician? *

Yes

No

Do they require an Epi-Pen? *

Yes

No

Can your child have this item as an ingredient in products? (example: egg allergy but can have bread with eggs, milk allergy but can have cooked in French toast) *

Yes

No

Please list any items that you use as a substitution (example: soy milk, rice milk, Udi’s bread, etc)

Does your child have any dietary needs based on personal preference or religious reasons? *

Yes

No

If yes, please explain and be as specific as possible.

Are you willing to provide any specialty items that are unavailable through our vendors? *

Yes

No

Please provide a contact name and number for the person responsible for this camper. A Registered Dietitian from FreshPicks Café may need to contact you with any questions.

Name *

First Last

Phone *

### - ### - ####

Signature *

Clear

Signature Date *

MM / DD / YYYY