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_____________________________________________________________________________________
Great Living Through Greater Choices @ Bi-Co Dining Services
Student 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
Student 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
Needs to Avoid:
Special Instructions:
Additional 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:
Nicole Patience, Dining Services, Bryn Mawr College, 101 North Merion Avenue, Bryn Mawr, PA 19010
If confidentiality is not required please email this form to the Bi-Co Dietitian Nicole Patience at npatience@brynmawr.edu
