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Lunchy - Special Dietary Questionnaire

If your child requires a specialised diet for ethical, religious, or medical reasons, please fully complete this form and return to the school. (Please complete one form per child)

Please note, specialised diet medical forms may require a signature by a paediatrician, GP or registered dietitian.
PART A - CONTACT DETAILS
Student Name
Year Level
Class/Room
PARENT/CAREGIVER DETAILS

I give permission for the information in this form to be shared with the lunch supplier, for the purpose of providing my child with a safe lunch.
Contact Name
Contact Phone Number

Area CodePhone Number
Signature

Clear
Date

MonthDayYear
Date
PART B - RELIGIOUS, CULTURAL, OR ETHICAL DIET REQUIREMENT
Does your child require a Cultural, Religious, or ethical diet (e.g. halal or vegan diet)?Please specify the type of diet required:

VegetarianVeganHalalNo Beef No pork productsNo pork products / No SeafoodNo BeefNo pork products
Other (please specify)
Other relevant information
PART C - MEDICALLY PRESCRIBED ALLERGY/INTOLERANCE DIET REQUIREMENT
Does your child have a medically prescribed food Allergy/intolerance such as:

Nuts (Note all meals provided by Eat My Lunch are nut free)EggDairy/Milk/Lactose productsSoyWheat/GlutenSeafoodSeasameKiwifruitLegumesBerriesCoconut
Other* (please specify)
Please describe the reaction that your child has (e.g. anaphylaxis, hives etc.)
Sample Specialised Diet Medical Form

(only required if other allergy/intolerance is selected)

TO BE RETURNED TO SCHOOL OFFICE (or filled in online)
Date

MonthDayYear
Date
Dear (Doctor's name)
DOB
NHI Number
I confirm that the above student requires specialised diet provision.
Diet required
Any other additional relevant information
Signed

Clear
Consultant/ General Practitioner/ Paediatric dietitian
Should be Empty: