Worry Less Pantry Application Worry Less Pantry Application Please fill out the form below and your application will be reviewed. Thank you! Name * Name First Name First Name Last Name Last Name Date * Email * Student ID * Student Year. If you are filling this out over the summer, please indicate what year you will be in the upcoming fall semester. * FreshmanSophomoreJuniorSenior Student Year. If you are filling this out over the summer, please indicate what year you will be in the upcoming fall semester. Year you will graduate * What is your reason for requesting access? If you have food allergies, please list all food allergies below. * Have you had allergy/celiac testing in the last 5 years? Yes No OtherOther Do you have medical documentation you can submit to the dietitian Yes No pendingpending If you have (a) food allergy(ies), who was it diagnosed by? * MyselfPhysicianOther Is your food allergy or need for this pantry registered with Student Health Services? * YesNoOther Do you have any other dietary preferences, intolerance, restrictions? * VeganVegetarianKosherNoneOther Do you have any other dietary preferences, intolerance, restrictions? Are you a student athlete? * YesNo Additional information that we should be aware of. Submit If you are human, leave this field blank.