Food Allergy and Intolerance Notification Form

Food Allergy and Intolerance Notification Form

This form should be completed by the parent or guardian of pupils under the age of 18.
Name of Pupil:*

First NameLast Name
Year Group:*

Does your child have an intolerance or allergy to any of the following? (Please add yes where applicable)

	Intolerant	Allergy	Medically Diagnosed **	Epi Pen/Autoinjector
Peanuts
Nuts
Eggs
Milk
Sesame Seeds
Molluscs
Crustacean
Celery
Cereal containing gluten (please insert type of cereal) *
Soybeans
Mustard
Sulphites
Fish
Lupin

* Insert type of cereal containing gluten (for example, wheat, oat, barley, rye etc).

** If medically diagnosed, please can the medical document be sent to the school if you have not done so already.

Is your child allergic to anything else? If so, please list below. (Please can information be clear, for example: Allergic to Veg – what veg specifically? Allergic to legumes- which legumes specifically?)

	Allergen	Intolerant	Allergy	Medically Diagnosed**	Epi Pen/Autoinjector
1
2
3
4

Has your child been diagnosed with Coeliac disease? *
Where a pupil’s requirements are complex (for example multiple allergies, severe allergies which have been medically diagnosed or medically diagnosed allergens that do not fall under the 14 listed allergens of the Food Information Regulations), It may be necessary to provide the pupil with a plated meal.
The menu cycle for this pupil will be planned, and a meal will be prepared in a separate area or at a separate time from the meals containing the pupil’s allergens. The meal will be wrapped and labelled to protect it from cross-contamination and checked by two members of the catering team.
If we deem it necessary for the safety of your child, do you agree that we may prepare a plated meal? *
PARENT/GUARDIAN ACCEPTANCE

Whilst Holroyd Howe can provide meals which do not include nominated allergens, we cannot guarantee that dishes do not contain traces of allergens, as they will be stored and prepared in the same areas as nominated allergies.
There is a risk of cross-contamination on display counters, particularly selfservice areas such as salad bars and dessert counters.

Please be aware that while Holroyd Howe do not use nuts in any of the food they prepare and serve they are unable to guarantee that dishes/products served are totally free from nuts/nut derivatives, due to the use of precautionary allergy statements such as ‘may contain’ which are used by their suppliers.

Once this completed form has been received, a meeting can be arranged between the catering manager, school and the parent/guardian to discuss your child’s food requirements in more detail.
Data Protection – please tick where you agree/give permission:
I’m happy for my child’s allergen information and photo (where provided) to be passed to Holroyd Howe to enable them to assist the school in correct food provision *
I confirm that the information supplied within this document is correct. Any changes in my child’s allergy/intolerance status will immediately be highlighted to the school in writing:
Name of Parent/Guardian completing this form:*

First NameLast Name
Date:*

DayMonthYear
Date
Contact Telephone number:*
Contact email address:*
Please add any dietary preferences (e.g., vegetarian/vegan etc)
Should be Empty: