Food Allergy Form

(*) denotes required information.

* Student Name:

* Phone:

* Email:


Fish:
Which fish?

How severe-ingest/inhale/on contact


Shellfish:
Which shellfish?

How severe-ingest/inhale/on contact


Tree Nuts:
Which nuts?

How severe-ingest/inhale/on contact


Peanuts:
How severe-ingest/inhale/on contact


Milk:
How severe-ingest/inhale/on contact

Is it an allergy or an intolerance?


Eggs:
How severe-ingest/inhale/on contact


Wheat:
Do you have a Wheat Allergy or Celiac Disease?


Soy:
How severe-ingest/inhale/on contact


Do you carry on Epi Pen?
yes no


Do you wear a Medic Alert bracelet? www.medicalert.com
yes no

Food Allergy Disclaimer
Gettysburg College Dining Services makes every attempt to identify ingredients that may cause allergic reactions for those with food allergies. Every effort is made to instruct our food production staff on the severity of food allergies. In addition, we label items with possible allergen-containing ingredients; however, 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. Customers concerned with food allergies need to be aware of this risk. Dining Services will not assume any liability for adverse reactions to foods consumed, or items one may come in contact with while eating at any College establishment. Students with food allergies are encouraged to contact Dining Services 717-337-6326 for additional information and/or support.