Food Allergies for Nourish

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Please fill in this form if your child has any food allergies.

This form will go directly to Nourish our new caterers who will share the details with our Chef

If you have any queries or require further information please contact Nourish on 02087781111/office@nourish.co.uk

Child's First name *

Child's Surname *

Year/Class *

Medical Diagnosis *

Please list any dietary requirements and associated information from a medical professional (if Other, please provide details)

Food Allergies or Intolerances

Type 1 Diabetes

Coeliac Disease

PKU

Other:

Required

Medically Prescribed Diet *

Please tick all foods which must not be consumed (if Other, please provide details)

Celery

Gluten (Wheat, Barley, Oats and Rye)

Crustaceans (Prawns, Crab, Lobster etc...)

Eggs

Fish

Lupin

Milk

Molluscs (Mussels, Oysters etc...)

Mustard

Peanuts

Tree Nuts (Almonds, Hazelnuts, Walnuts, Brazil Nuts, Cashews, Pecans, Pistachios, Macadamia Nuts)

Sesame Seeds

Soya/Soybeans

Sulphur Dioxide & Sulphites

Other:

Required

Record any exemptions below (e.g. eggs may be consumed if baked) *

Put NA if none

GP/Registered Dietitian Details *

Please include Name, Address, Email and Telephone

Please make sure you return this form with medical evidence (e.g. a letter from your GP or dietitian) to avoid delays in your application. *

Please email your medical evidence to jdpoffice@wale.at (if NO, please provide details under Other)

Yes, I have emailed the medical evidence to jdpoffice@swale.at

Other:

Parent/Carer name & relationship to child *

Please sign below to confirm that the information you have provided is correct and that you understand and accept that:

▪ Pabulum will make every effort in providing your child with food to meet their dietary requirements

▪ Pabulum will inform the parent/carer whether special dietary requirements cannot reasonably be provided safely and to an acceptable level

▪ Pabulum cannot guarantee that the food has been processed and/or prepared in an allergen free environment and so may contain traces of allergens

▪ The information you have provided in this form will be shared with a representative from your school to allow appropriate arrangements for your child’s dietary requirements

▪ You, as the parent/carer, are responsible for updating Pabulum with any dietary changes for your child.

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