Special Diet Information Form
Food allergies, intolerances and other dietary-related medical conditions are a growing concern for schools.  Children who are affected can suffer a severe or even fatal reaction if they eat or come into contact with food they’re allergic to.

If your child has any special dietary needs please complete this form as accurately as you can, describing any:
• Food allergies (for example to cow’s milk)
• Food intolerances (for example to gluten)
• Other dietary-related medical conditions (for example coeliac disease)

Please don’t use the form to describe your child’s food likes and dislikes.

Once we get this information, we’ll share it with our catering partner Sodexo Ltd, so they can make sure your child gets alternative meals that are safe for them.   If your child’s condition changes after you send us the form, you need to tell the school as soon as possible.

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Email *
Child's details
Child's surname *
Child's first name *
Class/Form (or Year group if not known)
Does your child have a food allergy
Please provide details of the child's / young persons food allergy.
Please include as much information as possible specific to your child's food allergy.  Can he/she tolerate products that say 'may contain' for example raw / cooked eggs, nuts (types of) and/or peanuts?
Food Allergy *
Required
More information about your child’s food allergy  
For example: Can they tolerate products that say ‘may contain traces’? What types of nuts are they allergic to – or should they avoid all nuts? Should they avoid all forms of the allergen - or can they tolerate some forms, for example raw, baked or cooked?
My child can tolerate products that say may contain *
Has this food allergy been medically diagnosed *
If yes, please provide a copy of the medical diagnosis (this can be a doctor's or a nutritionist's diagnosis letter) via email to: FirstAid@chschool.co.uk or by post to First Aid, Cheadle Hulme School, Claremont Road, Cheadle Hulme, SK8 6EF.           I understand that until I have provided you with the medical assessment my child will receive a restricted diet.
Does your child carry an Auto-Injector? *
If your child suffers from any other medically diagnosed dietary-related conditions (like coeliac disease), please provide the information here.
If your child has any food intolerance, please provide as much information as possible about your child’s condition here.
Parent/Guardian Name *
Relationship to the child *
Contact Phone Number *
Emergency Contact Name *
Emergency Contact Number *
Declaration
I am aware of the School's policies and procedures related to Allergy Management (accessible through https://www.cheadlehulmeschool.co.uk/chs-life/food-lunch-arrangements).

I understand that as a Parents/Carer I have primary responsibility for my child’s health, and will provide full information about their allergy condition, including the prescription and use of medication or medical equipment.

I agree to information about my child’s allergy and any related doctor’s or registered dietician’s medical assessment being provided to the school’s catering partner Sodexo (including any other relevant personal data, like photographs, if I’ve agreed with the school), solely so they can provide the right alternative meals for my child.

Name of person submitting the form *
A copy of your responses will be emailed to the address you provided.
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