Food Allergy Form
EBIC will make reasonable accommodations for medically diagnosed food allergies/restrictions that do not cause undue burden on the college.
Name
*
First Name
Last Name
Check the foods that have caused an allergic reaction:
*
Rows
Low Risk
High Risk
Peanuts
Fish/Shellfish
Eggs
Peanut or nut butter
Soy products
Milk/Lactose Intolerant
Nut oils
Tree nuts (Walnuts, almonds, pecans etc.)
Mushroom
Gluten
Other
Please enter any other foods that have caused an allergic reaction and any other applicable dietary restrictions:
Do you have a reaction when:
*
Eating the food(s)
Touching the food(s)
Smelling the food(s)
Other
How quickly do the signs and symptoms appear after exposure to the food(s)?
*
Seconds
Minutes
Hours
Days
Other
Additional notes you want to add
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Signature
*
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