Great Living Through Greater Choices @ Bi-Co Dining Services
dent Name: __________________________________College:
Bryn Mawr Haverford, Class of ________
Cell number: (____) ____-______ Email: __________________________ College ID Number: ________________
Food Allergies/Intolerance(s) or Health Conditions that require a special diet:
__ ___ .
Emergency Contacts:
Call Campus Safety, BMC 610-526-7911 or HC (610) 896-1111, for severe allergic reaction
Medical doctor: _________________________________________ Phone: (____) ____-_______
Parent/Guardian: _______________________________________ Phone: (____) ____-_______
Other Emergency Contact:________________________________ Relationship to student: _________________
Phone: (____) ____-_______
Student reports she/he carries an EPI pen:.
Yes No
dent requests to participate in non-confidential email list to notify of Dining Services updates sensitive to those
with food allergies or special diet needs:
Yes No
eeds to Avoid:
ecial Instructions:
ditional Notes:
I verify this information is complete and accurate and will be updated by the student if changes apply.
Name of person who completed the form:______________________________ Date: ______________
Inter-Departmental Information
Date of Initial Interview: ___________ Interviewer: ________________________ .
Circle locations student uses: BMC [Erdman / Haffner / Uncommon Grounds] Haverford [DC / The Coop]
To ensure absolute confidentiality, please mail the form to:
Natalie Zaparzynski, Dining Services, Bryn Mawr College, 101 North Merion Avenue, Bryn Mawr, PA 19010
If confidentiality is not required email this form to Bi-Co Dietitian Natalie Zaparzynski at