Special Medical Diet

Special Medical Diet

Parent Request Form
Name of Child*

First NameLast Name
Date of Birth*

DayMonthYear
Date
New Diet or Change to Existing?*

NewChange
Class*
Parent or Guardian Name*

First NameLast Name
Contact Number*
Contact Email*
example@example.com
Doctor, Dietician Name (Optional)

First NameLast Name
Doctor, Dietician Contact Number (Optional)
Section 1

to be completed by the parent/guardian
Please clearly tick the food allergen boxes and list the dietary exclusions relevant to the child.*

CeleryCereals Containing GlutenCrustaceansEggsFishLupinMilkMolluscMustardNutsPeanutsSesameSeedsSoyaSulphurDioxide /SulphitesOther
Other medical conditions and dietary requirements
SECTION 2

to be completed by the parent/guardian
Declaration*

I hereby authorise Catering Leeds to provide a school meal which meets the special medical dietary requirements of the child noted above. I accept it is my responsibility to inform Catering Leeds in writing of any special medical dietary changes
Signature

Clear
Date*

DayMonthYear
Date
Parent or Guardian Name*

First NameLast Name
School may provide a photograph of your child to Catering Leeds to enable identification. If you do not consent to this please tick the option below.*

I AM happy for a photograph to be providedI AM NOT happy for a photograph to be provided
Please note, all personal details for provision of special diets held by Catering Leeds are processed in line with General Data Protection Regulation (GDPR) and Data Protection Act 2018. https://www.leeds.gov.uk/privacy-and-data/service-privacy-notices/business-and-licensing-privacy/civic-enterprise-notice
Should be Empty:

Special Medical Diet

Section 1

SECTION 2