We understand that food allergies can present serious problems for some of our pupils. This form is designed to collect information about pupils who have allergies/intolerances so that we can cater for them appropriately. This form should be completed by the parent or guardian of pupils under the age of 18 and returned to the school.

Name of pupil: *

Part 1: To be completed by parents/guardian

Does your child have an allergy or intolerance to any of the following allergens?
Any other allergen not stated above?

If you ticked any of the above boxes please provide further details of the nature of the allergy/intolerance:
1b. Has this Allergy or Intolerance been medically diagnosed?
1c. Does your child require an Epipen or any other medication for food allergies? *
If yes, please give details
1d Holroyd Howe use a colour coding system to identify special diets. Please tick which applies to your child:

If you have ticked RED please note:

Where Holroyd Howe cater for pupils under the age of 16 with a special diet in the RED category, we strongly recommend that a freshly prepared pre-plated meal is provided for them. A pre-plated meal is the safest way to minimise the risk to the pupil. If you DO NOT want a pre-plated meal to be provided to your child then please see Part 4.

Once this completed form has been received, a meeting can be arranged between the Catering Manager and the parent/guardian or school to discuss your child’s food requirements in more detail.

Part 2: Religious Preferences

Please provide details of non- permitted foods due to religious faiths and beliefs in the box below:

Part 3: Parent/Guardian Acceptance

Whilst we 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 allergens. There is a risk of cross contamination on display counters, particularly self-service areas such as salad bars and dessert counters. Please be aware that while Holroyd Howe do not use nuts in any of the food we prepare and serve, we 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 our suppliers.

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’m happy for my child’s allergen information and photo (where provided) to be displayed next to the main servery area to enable the catering staff to check allergy information. *

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:

Name of Parent/Guardian completing this form: *
Date: *
Daytime contact telephone number: *

Part 4

If you have ticked RED and DO NOT want a pre-plated meal to be provided to your child then please sign below:

I hereby confirm that I do not want my child to receive a pre-plated meal. *

I am aware that:

  • Holroyd Howe 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 our suppliers.
  • There is a risk of cross- contamination on display counters, particularly at self-service areas such as salad bars and dessert counters.
  • The meals provided to your child will be prepared in the same areas as nominated allergens.

Name of Parent/Guardian completing this form:
Date:

Please leave the next box blank or your submission will not be accepted: