Food Allergies & Intolerance Form
2025-2026
Do not complete this form if you do not have a food allergy or special dietary need.
Student Name
*
First Name
Last Name
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Student Email
*
example@iowalakes.ed
Student ID:
*
Room #
*
Iowa Lakes Campus
*
Please Select
Emmetsburg
Estherville
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Academic Level
Please Select
New Freshman
New Transfer
Returning Student
Which semester are you requesting accommodations?
Fall
Spring
Summer
Do you have a medical diagnosis (please explain):
*
Student's Food Allergies
Rows
Severe Symptoms
Mild Symptoms
Peanut
Tree Nut
Fish
Shellfish
Egg
Wheat
Dairy
Soy
Sesame
Celiac Disease
Lactose
If you have any other allergies or food sensitivities, please explain here:
List the types of foods you CANNOT or are RESTRICTED from eating:
Do you carry an EPI-PEN?
*
Yes
No
Is the EPI-PEN carried with you at all times?
*
Yes
No
Do you have an ALLERGY OR ANAPHYLAXIS Action Plan?
*
Yes
No
Are you able to monitor/prevent their own exposure?
*
Yes
No
Does the student wear a medical alert bracelet, necklace, watchband, etc?
*
Yes
No
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: