Dietary Restriction & Food Allergy Form Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Phone Number Question Title * 4. Email Address Question Title * 5. Please indicate if you are a Visitor First Year Student Returning Student Other Question Title * 6. Anticipated date that you will first be dining on campus Date Date Question Title * 7. Residential restaurant that you will visit and/or frequent The Hub - Tampa Juniper Dining - Tampa Champion's Choice - Tampa The Nest - St. Petersburg Question Title * 8. Food allergy (only check wheat for wheat allergy, not Celiac disease) Peanuts Tree nuts Fin fish Shellfish Wheat Soy Dairy Eggs Other Question Title * 9. Other food allergy Question Title * 10. Food intolerance Gluten (check for Celiac disease) Lactose Other Question Title * 11. Other food intolerance(s) Question Title * 12. Other dietary restrictions (Please list any other medical condition or religious observances requiring special dietary needs or restrictions here) Question Title * 13. Is the student under care of a physician for their food allergy or food-based condition? Yes No Question Title * 14. What are the medically necessary accommodations to help manage the health of the student? Question Title * 15. What are the preferred food substitutions, if any? Question Title * 16. What types of contact will cause a reaction? Airborne Ingestion of food Trace cross-contact Question Title * 17. Please explain: Question Title * 18. What are the student’s possible reactions to the above-indicated allergen(s) or conditions? Question Title * 19. Does the student understand the food allergy or medical condition, how to manage it, and keep necessary medication with them? Question Title * 20. Is there any other information you would like to share to help us better meet the student’s needs? Done