Housing & Dining: Food Allergy/Celiac Disease/Medical Diet Form

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Food Allergy: Please Check All That Apply * 🛈
 
Is an Epi-Pen prescribed by your physician?
If yes, do you carry your Epi-Pen with you at all times?
Gluten Free Diet
Do you have Celiac Disease?
Are you gluten intolerant?
Following GF diet for other reasons?
Medical or Special Diet
Do you have a medical or special diet?
Permission to share information? This form will be directed to Shavaun Cloran RD, at WPI Dining Services, Regina Roberto, Director of WPI Health Services, and Jillian Brooks, Nurse Practitioner of WPI Health Services
I give WPI Health Services and WPI Dining Services permission to share information about my food allergy to those personnel who can assist in my accommodations to the dining facilities at WPI. *
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Refund Statement: Refunds are issued at the discretion of the Event Coordinator or Department Manager. For inquiries regarding refunds please contact the managing department of your event/program, or email bursar@wpi.edu.