Food Allergy & Intolerance update

Holroyd Howe Food Allergy and Intolerance Update Form for School Pupils.

"*" indicates required fields

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Select School

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 parent/guardian

1A. Does your child have an allergy or intolerance to any of the following allergens?
Lit of Allergens please select all which apply.
1B. Has this Allergy or Intolerance been medically diagnosed? (If yes, please provide a medical note to the school)
1C. Does your child have an EpiPen or autoinjector?
1D. Do you require a meal to be prepared and plated separately from the main dishes?
2A. Does your child follow a Religious diet?
3A. Has your child chosen to follow any of the following dietary preferences?

1D. Where a pupil’s requirements are very complex (for example multiple allergies, severe allergies which have been medically diagnosed or medically diagnosed allergens that do not fall under the 14 listed allergens of the Food Information Regulations), it may be necessary to provide the pupil with a plated meal. The menu cycle for this pupil will be planned and a meal will be prepared in a separate area or at a separate time from the meals containing the pupil’s allergens. The meal will be wrapped and labelled to protect it from cross-contamination and checked by two members of the catering team.

Part 2: Parent/Guardian Acceptance

Whilst Holroyd Howe can provide meals which do not include nominated allergens, they 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 they prepare and serve, they 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 their suppliers. Once this completed form has been received, a meeting can be arranged between the catering manager, school and the parent/guardian to discuss your child’s food requirements in more detail.

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.
Name of Parent/Guardian completing this form*
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