WSU Dining Services

Special Dietary Needs Form and Waiver

Conference Information

Camp/Conference Attending

Beginning Date *

Participant Information:

Participant Name

Participant Age

Participant Phone:

Participant Email

Parent/Guardian Information

Parent or Guardian Name (if participant is under 18 years of age):

Relationship to Participant:

parentGuardianCellPhone

Parent/Guardian Home Phone

Parent/Guardian Email:

Food Allergy(s)

Food Allergy

Dairy
Soy
Eggs
Peanuts
Tree Nuts
Fish
Shellfish
Wheat (do not check this for celiac disease of gluten sensitivity)
Sesame

Other Allergy

Prior to the camp/conference, camp/conference participants or the participant's legal guardian are encouraged to contact Dining Services's Dietitian, Alice Ma, RD at (509)335-4785, alice.ma@wsu.edu. Dining Services will make every attempt to meet special diet and food allergy needs, but cannot guarantee food service for all food allergies/special dietary requirements.

Food Intolerance

Gluten (celiac disease of non-celiac sensitivity, includes wheat, barley, oats, rye
Lactose

Dietary Needs Questionnaire part 2

University Housing and Dining Services does not provide assistance or administer injections due to allergic reactions and does not carry or provide stock epinephrine in any dining hall. Please answer the following questions to better help us with your needs:

What are the preferred food substitutions, if any? (soy butter for peanut butter, gluten-free breads, soy milk, etc.):

What types of contact will cause a reaction?

Airborn
Trace Cross-contact
Actual ingestion of food
Other

If other, Please explain reaction:

Is there any other information you would like to share to help us meet the Participant’s needs?