Allergy and Dietary Needs Intake Form If you are human, leave this field blank.Student InformationStudent InformationFirst Name *Last Name *Birth Date *Cell #Home #Work #Preferred Contact Email *Other Email Parent or Guardian InformationNot RequiredParent or Guardian NameRelationship to StudentCell #Home #Work #Email Food Allergie(s)/ Intolerance(s)Food Allergie(s)/ Intolerance(s)To better understand how to accommodate your dietary needs on campus, please list all allergies, intolerances, or special dietary needs that apply.Allergies, Intolerance, or Health Condition *PeanutsTree NutsFishShellfishMilkSulphitesEggsSoyDiabetes MustardWheatGlutenCeliac DiseaseLegumesStrawberriesKiwiPeppersTomatoOther Allergies (Please list in detail)Which foods would cause you to have an anaphylactic response (please list) *If your allergy could result in an anaphylactic reaction, do you carry an epi-penYesNoAny other information you would like to shareWhat are your favourite foods? Upcoming SessionsUpcoming Sessions for Students with an Allergy, Intolerance or Other Special Dietary NeedsSpecific dates are currently not set, however: One-on-one sessions will be held during the week leading up to move in day, and into the first 2 weeks after arriving on campus (August 26 -September 13 2019). Please note: earlier appointments will be reserved for students with anaphylactic allergies. Group sessions for students with allergies and celiac disease will be held close to move in day (August 31st). All other group sessions will be held within first two weeks (September 2nd - September 13th). Please contact Hospitality Services if you would like further information: Email: dining.queensu.ca Phone: 613-533-2953One-on-one appointment with Registered Dietitian and/or Chef Skype meetings in the week leading up to Move in Day In person meetings on move-in day and during the first week of schoolGroup Sessions with Registered Dietitian and/or Chef Navigating Campus Food with Peanut and/or Tree Nut AllergyNavigating Campus Food with Celiac Disease or Gluten IntoleranceNavigating Campus Food as a Vegan or Vegetarian Navigating Halal Food on Campus Do you have any suggestions for a session currently not listed? Further QuestionsAdditional InformationAdditional QuestionsPlease provide any additional questions that you may have with regards to your allergy or nutrition needs.For security verification, please enter any random two digit number. For example: 50Submit Food photo created by freepik – www.freepik.com
