FOOD ALLERGY & FOOD INTOLERANCE MANAGEMENT Question Title * 1. Pupil and Parent Details Name of parent Name of child Address Postcode Telephone Number Email Address Question Title * 2. Have you had a letter about managing Food Allergies and Food Intolerance? The letter can be found here. Please note you must read this before your child starts school. Yes No Question Title * 3. Tick the box next to the foods to which your child is allergic or intolerant My child has no intolerance to allergies to any food Peanuts Fish Nuts Seafood Milk Sesame Gluten Eggs Soya Celery Lupin Mustard Sulphur Dioxide Can you detail if these are allergies or if your child is intolerant. Question Title * 4. Is your child allergic to any other food item? Question Title * 5. Is a copy of a medical diagnosis available and can Harrison and the school view it? Yes No Question Title * 6. Has your child suffered a previous allergic reaction to any of these foods? Yes No Question Title * 7. Is the allergy life threatening? Yes No Question Title * 8. I understand that I am responsible for ensuring that accurate information about the food allergies or intolerances affecting the child named above is given to the school and the caterer and for the need to notify any changes in relation to the food allergies or intolerances suffered by my child.I consent to such information being shared between the school and the caterer (Harrison Catering Services Limited) Yes No Question Title * 9. I give permission for a photograph of my child to be displayed in the kitchen to assist in correctly identifying my child when being served? Yes No Question Title * 10. Parental Signature Name Signed Date I am happy to have a telephone conversation to confirm details regarding my child if Harrisons feel it necessary. Please note that whilst all reasonable precautions will be taken to make sure the food is safe for your child to eat, there can be no absolute guarantee that the food will not contain anything to which your child has an allergy or intolerance Done