Allergy and Dietary Needs Intake Form

Student Information

First Name *

Birth Date *

Phone #

Are you on or will you be on a meal plan?

Last Name *

Preferred Contact Email *

Other Email

Parent or Guardian Information

Not Required

Parent or Guardian Name

Relationship to Student

Cell #

Home #

Work #

Email

Food Allergy and Dietary Needs

Do you have a food allergy?

Yes

No

Do you carry an epinephrine device?

Yes

No

Legumes

Shellfish

Tree Nuts

Other Allergies (Please list in detail)

Which foods would cause you to have an anaphylactic response (please list) *

When was the last time you experienced symptom(s)/a reaction? *

Do you have any food intolerances?

Yes

No

Please list intolerance (e.g. lactose intolerance):

Do you have any food related medical condition(s)?

Yes

No

Please list food related medical condition(s)

Celiac Disese

Crohn's Disease

Diabetes

Irritable Bowel Syndrome

Other food related medical condition(s)

Please list religious observance(s) requiring dietary accommodations

Dietary needs not listed

Any other information you would like to share:

Preferences / Go-to meals

Breakfast

Lunch

Dinner

Snacks

Book an appointment

Thank you for filling out Hospitality Services' Allergy and Dietary Need Intake Form. Below are next steps we encourage you to take:

Book a virtual appointment with our Hospitality Services’ Registered Dietitian through the summer months here (choose “Allergy/Dietary Needs Appointment for Future Students”)
Appointments are also available in person upon arrival to campus and throughout the year. These can also be booked through the same link.

If you have any questions, Hospitality Services can be reached at 613-533-2953 or by emailing dining@queensu.ca

Additional Questions

Please provide any additional questions that you may have with regards to your allergy or dietary needs.

Disclaimer

Queen’s Hospitality Services understands the seriousness of food allergies. A team approach is the best preparation for a safe school year free of allergic reactions.

I understand that Queen’s Hospitality Services makes every attempt to identify and label ingredients that may cause allergic reactions for those with Health Canada’s priority food allergens. Every effort is made to instruct our food production team on the severity of food allergies and safe handling procedures. Our chefs and management team are also AllerTrain certified on managing food allergens and gluten.

However, there is always a risk of cross contamination due to the nature of the business as Hospitality Services does not have an allergen free facility. There is also a risk that sourced foods from manufacturers we use could change the formulation at any time without our knowledge. Therefore, we cannot assume any liability for adverse reactions.

Although Hospitality Services makes every effort to identify ingredients and avoid cross contact, it is the responsibility of any individual with food allergies to self identify and ask for assistance when ordering food. Customers with allergies need to be aware of the risks, need to be diligent in managing their diet and are encouraged to carry their epinephrine device at all times. Customers are encouraged to “Ask Before you Eat”: please ask to speak with a Chef or Manager when in doubt. Customers can also book an appointment with the Hospitality Services’ Registered Dietitian for further support by going to dining.queensu.ca. It is better to ere on the side of caution then take risks when it comes to food safety.

We will do our best to make sure you have a safe and enjoyable experience when visiting our foodservice locations.

Please note: The Information you have provided in this form has been sent to Hospitality Services’ Registered Dietitian with relevant information sent to our culinary leads so as to better assist you with your dietary accommodations.

Do you agree to the disclaimer above? *

Yes, I agree

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