Food Allergies/Special Diets Form
Dates :___________________________________ to ___________________________________
Attendee Information
Please complete this form if the attendee has a food allergy or special diet need!
Age:_________________ Sex:________ Birth Date: ____________________________________
Parent/Guardian Name:_________________________________________________________________
Phone (Cell):__________________ Work:__________________ Home:____________________
Please provide a medical statement describing the dietary restrictions due to the food allergy, diet and/or
intolerance, from the Attendee’s Physician.
Circle all that apply:
Peanut Wheat Gluten Dairy Shellfish Soy Eggs Fish Tree nuts Other:_________________
Other Special Diet needs or restrictions:____________________________________________________
A minimum of 10 business days prior to the camp/program, attendees or attendees’ legal guardian is request to contact the
Camp Director with specified food allergies/special diet needs. Alabama State University contracted food service provider,
Aramark Food Services, LLC will make every attempt to meet special diet and food allergy needs but cannot guarantee food
service for all requests.
Food Allergy Disclaimer
Aramark Food Services, LLC will make every attempt to identify ingredients that may cause allergic reactions for those with food allergies. Every effort is made
to instruct our food service staff on the severity of food allergies. In addition, there is always a risk of contamination. There is also a possibility that
manufacturers of the commercial foods we use could change the formulation at any time, without notice. Attendees concerned with foods consumed, or items
one may come in contact with while eating at any camp dining venue. Attendees with food allergies are encouraged to contact Saundra Brown, Camps &
Programs at (334) 229-8487 or email for additional information and/or support.
Food Allergy/Intolerance Chart
Mode of
Yes or No
Aware of
Please note: Special diet requests are for food allergies, religious restrictions, and other health-related needs. Request should not
be made for food preferences, personal taste, or for “picky eaters.” The camp cannot accommodate and honor every request.
Vegetarian alternatives are available at each meal and should not be requested here.
The Eight major Allergens Include: Milk, Eggs, Peanuts, Tree Nuts, Wheat, Soybeans, Fish, and Shellfish. These allergens are to
blame for 90% of allergic reactions to food, may be severe, and may cause food anaphylaxis in some individuals.
Food intolerances such as lactose intolerance and gluten intolerance/sensitivity (Celiac Disease) are not allergies but individuals
may have special dietary needs associated with these conditions.
Is there any other information you would like to share to help us meet the camper’s needs?
By signing this I am certifying I understand the disclaimers contained in this form and I verify the information provided is true and
_____________________________________ _____________________________
Attendee/Parent/Guardian Date