Samford Dietary Restriction Survey

Samford Dietary Restriction Survey

Samford University makes it a priority to accommodate students with dietary restrictions and food allergies. We also provide accommodations for students whose diet may differ due to religious and cultural backgrounds. You are in good hands with trained staff. To better help us with your specific needs, please fill out the following form and we will be in touch to discuss on campus management.

First Name:*

Last Name:*

Phone Number:*

Phone

E-mail:*

What is Your Campus Affiliation?*

First Year Student

Returning Student

Faculty/Staff Member

Visitor

Anticipated Date You Will First Dine On Campus*

Food Allergies:*

Egg

Fish

Milk

Peanuts

Tree Nuts

Sesame

Shellfish (Crustacean)

Shellfish (Mollusk)

Soy

Wheat (Do Not Select For Celiac Disease)

Other

None

Other Food Allergies

Please Indicate Any Food Intolerances/Sensitivities, Restrictions, Religious Diets, or Other Dietary Needs?*

Gluten (Celiac)

Gluten (Non-Celiac Sensitivity)

Halal

Kosher

Lactose Intolerant

Pescatarian

Vegan

Vegetarian

Other

None

Please Identify Any Other Dietary Needs:

Is the student under care of a physician for their food allergy or food-based condition?

Yes

What are the preferred food substitutions, if any? (dairy alternative, gluten-free bread, etc)

Please note that specific brands may not be available

Do You Understand the Dietary Restriction, How to Manage It, & Keep Necessary Medication with You?*

Yes

Is There Any Other Information You Would Like To Share To Help Us Better Meet The Student’s Needs?

Send me a copy of my responses

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