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

Date (MM/DD/YYYY) * +

Your Name *

Email (WPI email is preferred, if available) *

Food Allergy: Please Check All That Apply * 🛈

Milk

Soy

Wheat

Eggs

Fish

Shellfish

Peanuts

Treenuts

Gluten

Corn

Other (I.E Apple, Carrot, Sesame) Other (I.E Apple, Carrot, Sesame)

Is an Epi-Pen prescribed by your physician?

Yes

If yes, do you carry your Epi-Pen with you at all times?

Yes

Gluten Free Diet

Do you have Celiac Disease?

Yes

Are you gluten intolerant?

Yes

Following GF diet for other reasons?

Yes

Additional comments

Medical or Special Diet

Do you have a medical or special diet?

Yes

If yes, please describe

Permission to share information? This form will be directed to Shavaun Cloran RD, at WPI Dining Services, Lisa Pearlman, 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. *

Yes

Currently, what country are you physically present in? *

By providing the information requested in this form, you are consenting to WPI’s use of the provided information for the purpose for which the form is being used. See Privacy Policy Below.

Privacy Policy: https://www.wpi.edu/about/policies/privacy-policy

WORCESTER POLYTECHNIC INSTITUTE | 100 Institute Road | Worcester, MA | 01609-2280 | Ph: 508-831-5000