Mount St. Mary Academy Dining Services
School Payment Portal
Food Allergies and Sensitivities Form
To better serve you, please complete the following for our culinary team. A member of our management team will review and will contact you within 48-hours.
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Indicates required field
Child's Name
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First
Last
Your Name
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First
Last
Your Phone Number
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PLEASE CHOOSE YOUR CHILD'S ALLERGIES FROM THE LIST BELOW
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Fish
Shellfish
Tree Nuts
Peanuts
Dairy
Eggs
Soy
Wheat
Sesame
Other
Other
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Your Email
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HOW SEVERE IS THE ALLERGY?
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WHAT TRIGGERS THE ALLERGY? E.G. INGESTION, INHALING, CONTACT, ETC.
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DOES YOUR CHILD WEAR A MEDIC ALERT BRACELET
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Yes
No
DOES YOUR CHILD CARRY AN EPIPEN?
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Yes
No
IS THERE ANYTHING ELSE WE SHOULD KNOW ABOUT YOUR CHILD'S ALLERGY?
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Submit
School Payment Portal