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Food Allergy & Dietary Restriction Form

Document food allergies, dietary restrictions, known reactions, substitutions, and family instructions.

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Allergy documentation, emergency plans, physician instructions, meal substitutions, and food-service requirements vary by jurisdiction. Follow applicable healthcare and childcare licensing requirements.

Food Allergy & Dietary Restriction Form

Childcare Food & Nutrition Information

Child Information

Food Allergy

Known Reaction

Dietary Restrictions

Approved Substitutions / Meal Instructions

Emergency / Medical Instructions

Parent / Guardian Confirmation

I confirm that the information above is accurate and will notify the childcare program if my child's allergies, dietary restrictions, or instructions change.

Parent / Guardian Signature

Date

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