Summer Food Allergy Form

Summer Food Allergy Form
The purpose of this form is to collect information about your student’s food allergy and/or food-based medical condition (such as Celiac) to aid us in determining how best to accommodate the dietary needs of your student.

An allergy is an immune response that cause antibodies to respond to allergens. A food allergy is distinguished by the way the body’s immune system responds to specific food proteins. Therefore, it is important to note that a food allergy is not an “intolerance” to food or “sensitivity” to certain foods, but is a specific immune system response that triggers an allergic reaction that can range from mild to severe and life-threatening. A food allergy is also NOT a dietary preference (e.g. veganism, halal/kosher, paleo, etc.).
Please complete the following information:

Does your student have a food allergy or diagnosed food-based medical condition? *
Is your student under the care of a physician for his/her food allergy or food-based medical condition? *
Food Allergies and Food-Based Medical Condition(s)
Is your student able to monitor and prevent his/her own exposure?
Does your student know what foods to avoid?
Does your student ask about food ingredients?
Does your student read and understand food labels?
Does your student tell responsible adults about the allergy (including servers when necessary)?
Does your student firmly refuse a problem food?
Does your student wear a medical alert bracelet, necklace, watchband, etc. (for the identified food allergy/food-based medical condition)?
Washington University in St. Louis (the “University”) and its dining services provider, Bon Appetit (“Dining Services”), treat food allergies seriously. Dining Services provides several tools to assist those students with food allergies, including allergy and nutrition information on each dining location’s online menu. Students with food allergies (and their parents) are also encouraged to contact the University’s director of nutrition before the program begins to discuss the student’s food allergies. Ultimately, however, it is the responsibility of the student to judge whether or not to question ingredients or to choose to eat selected foods. Students with food allergies or other food-based medical conditions must be their own advocates and exercise caution at all times.

DISCLAIMER: Dining Services attempts to identify ingredients that may cause allergic reactions for those with food allergies. Dining Services instructs the food production staff on the severity of food allergies and the importance of labeling items with possible allergen-containing ingredients. However, there is always a risk of cross-contamination and the possibility that manufacturers of the commercial foods and products we use could change the formulation or substitute other ingredients at any time, without notice. Customers concerned with food allergies need to be aware of these risks. Additionally, Dining Services staff does NOT provide, or have training in the use of, Epi-Pens or other medications.

Finally, the University is an open campus. We cannot guarantee that students or other members of our community will not introduce allergens into the environment, even if a particular table or room is reserved for individuals with a particular allergy. Given the open flow of our dining facility, it is not feasible to fully prevent airborne allergen flow.

Parent/Guardian Certification
By submitting this form I certify that I have read and understand the foregoing and that the information submitted by me is complete and accurate to the best of my knowledge and belief. I understand that the University and Dining Services may share the information contained herein only with individuals employed by the University and Bon Appetit and/or with medical care providers who need to know such information in order to accommodate my student’s dietary needs, facilitate the health and safety of my student during the program or treat my student’s food allergies or allergic reactions.