Picture
of
Food
Participant
Allergies/SpecialDietsForm
☐BecketOutdoorCenter
ArrivalDate:
☐CampBecket ☐ChimneyCornersCamp DepartureDate:
☐BecketDayCamp
☐TSP
PARTICIPANTINFORMATION:
Thisformisrequiredforanyparticipantwithafoodallergyorspecialdietneed.
ParticipantName:
Gender:☐Mor☐F ParticipantAge: or BirthDate:
Participant
Phone(cell): Work: Home: email: IfMinor,ParentorGuardian:
Name:
RelationshiptoParticipant:
Phone(cell): Work: Home: email: FOODALLERGY(IES)/INTOLERANCES/SPECIALDIET:
Pleaseprovideamedicalstatementdescribingthedietaryrestrictionsduetothefoodallergy,dietand/orintolerance,fromthe
Participant’sPhysician.
Checkallthatapply:
☐Wheat/Gluten
☐Dairy
☐Fish ☐Shellfish
☐Soy☐Eggs ☐Peanuts
☐TreeNuts
☐Other(pleaselist): OtherSpecialDietneedsorrestrictions: Aminimumofthree(3)weekspriortothecamp/retreat/conference,participantorparticipant’sparent/legalguardianis
requestedtocontacttheFoodServiceDirectorattherelevantsiteatBecket-ChimneyCornersYMCA,ph:(413)623-8991
(ChimneyCornersCamp–MikMontiext127,CampBecket–ShazAtwellext154).Wewillmakeeveryattempttomeetspecial
dietandfoodallergyneedsbutcannotguaranteefoodserviceforallrequests.
Pleasenote:Specialdietrequestsareforfoodallergies,religiousrestrictions,andotherhealth-relatedneedsonly.Requests
shouldnotbemadeforfoodpreferences,personaltaste,orfor“pickyeaters.”Thecampcannotaccommodatetheserequests
andtheywillnotbehonored.Vegetarianalternativesareavailableateachmealandshouldnotberequestedhere.
Information:
TheEightMajorAllergensInclude:Milk,Eggs,Peanuts,TreeNuts,Wheat,Soybeans,Fish,andShellfish.Theseallergensareto
blamefor90%ofallergicreactionstofood,maybesevere,andmaycausefoodanaphylaxisinsomeindividuals.
Foodintolerancessuchaslactoseintoleranceandglutenintolerance/sensitivity(CeliacDisease)arenotallergiesbutindividuals
mayhavespecialdietaryneedsassociatedwiththeseconditions.
FoodAllergyQuestionnaire
Pleaseanswerthefollowingquestionstobetterhelpuswiththeparticipant’sneeds:
1.
2.
3.
4.
Whatarethepreferredfoodsubstitutions,ifany,fortheparticipant’sfoodallergy/intolerance?(soybutterforpeanut
butter,gluten-freebreads,soymilketc):
Whattypesofcontactwillcauseareaction?Checkandexplain:
☐Airborne/Aerosol ☐CrossContamination ☐Actualingestionoffood
Ifother,pleaseexplain:
☐Other
Hastheparticipanteverbeenhospitalizedduetoareactiontothisallergen(checkone)☐Yes
☐No
Istheparticipantfamiliarenoughwithhis/herallergythattheycanidentifywhenplacedinathreateningsituation?
Elaborateifneeded.
5.
6.
7.
8.
Pleasedescribeindetailwhathappenstotheparticipantwhenexposedtothisallergen.
Howlongdoesittakeforareactiontotakeplaceuponbeingexposedtotheallergen?
Whenwastheparticipant’slastreactionduetoexposuretotheallergen?
Onascaleof1-10,10beingtheworst,howsevereisthecamper’sreactiontothisallergen?
9. Hasthecampereverattendedacamp,orretreat,oreatenmealsoutsidethehome?
10. Ifyes,howwerethemealshandled?
11. Isthereanyotherinformationyouwouldliketosharetohelpusmeettheparticipant’sneeds?
FoodAllergyDisclaimer
Becket-ChimneyCornersYMCAFoodServicesmakeseveryattempttoidentifyingredientsthatmaycauseallergicreactionsforthosewithfood
allergies.Everyeffortismadetoinstructourfoodproductionstaffontheseverityoffoodallergies.Inaddition,thereisalwaysariskof
contamination.Thereisalsoapossibilitythatmanufacturersofthecommercialfoodsweusecouldchangetheirformulationatanytime,without
notice.Participantsconcernedwithfoodallergiesmustbeawareofthisrisk.FoodServicewillnotassumeanyliabilityforadversereactionsto
foodsconsumed,oritemsonemaycomeintocontactwithwhileeatingatanyBCCYMCAdiningvenue.Participantswithfoodallergiesare
encouragedtocontactFoodServiceat(413)623-8991foradditionalinformationand/orsupport.
BysigningthisIamcertifyingIunderstandthedisclaimerscontainedinthisformandIverifytheinformationprovidedistrueand
correct.
Signature:
Participant/Parent/Guardian:_________________________________________Date:__________
2