Worry Less Pantry Application

The Worry Less Pantry is a medical accommodation designed for students with celiac disease, peanut allergies, and/or treenut allergies. Additional medical dietary needs may be included. All students who apply will be contacted by the Dietitian to set up a formal application meeting. Thank you!

Name

First Name

Last Name

Date

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. 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

OtherOther

Do you have medical documentation you can submit to the dietitian

Yes

pendingpending

If you have (a) food allergy(ies), who was it diagnosed by?

Is your food allergy or need for this pantry registered with Student Health Services?

Do you have any other dietary preferences, intolerance, restrictions? Do you have any other dietary preferences, intolerance, restrictions?

Are you a student athlete?

Additional information that we should be aware of.

If you are human, leave this field blank.