Special Diet Registration Form Jan 2018 - Norse...
Transcript of Special Diet Registration Form Jan 2018 - Norse...
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SpecialDietRegistrationForm
TocompletethisformonlinepleasedownloadandsavethisPDF,completeall [email protected]
Alternativelyyoucanprintthisformandposttothefollowingaddress(Pleaseensureyoucompletebothpages:
NorseMenuDevelopmentTeamC/OAlisonParkerNorseCommercialServices51NorwichRoadHorshamStFaithsNorwichNR103HH
Please allow two working weeks for themenu to be arranged and in themeantime continue tosupplyapackedlunchfromhomeuntilamenuisinplace.
PleasenotethatonarareoccasionitmaynotbepossibleforNorsetoprovideaspecialdietsafelyandmayaskparentstoprovideapackedlunchonallorsomedays.Thisdecisionisnottakenlightlyand usually occurs when a child has a very restricted diet ormedical condition, coupledwith thelimitationsofcateringforlargenumbersinaschool.Inthesecircumstanceswefeeltheparentisbestplacedtoprovidefoodatlunchtoensureabalanceddietisprovidedforthatchildsafely.
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SpecialDietRegistrationForm
At Norse Commercial Services our menus adhere strictly to the School Food Standards and weendeavourtocatertothemajorityoftheschoolpopulation.Weareawarethatnoteveryoneisabletoeatallfoodssafely.Ifachildhasamedicallydiagnosedallergyorintoleranceorhealthcondition,wecanworkwithparents/guardiansandhealthprofessionalstodevelopanindividualmenuforthatchild. In order for Norse to provide a special diet menu for a child, parents/guardians shouldcompletethisinfull.
Pleasenote:Wecannotprovideamenuwithoutsupportingevidencefromamemberofyourchild’shealthcareteam.Ifyouhavearecentletterwrittentoyoufromyourchild’sconsultant,adietitianorotherhealthprofessionalpleasesendthiswiththisrequestformtoaddressbelow.Pleasenote:youwillnotneedaGP/healthprofessionalssignatureifthisevidenceisprovided.Otherwisepleaseseekadvicefromyourschoolnurse,whocanspeaktoyourGPifnecessary.
SchoolPostCodeTelephoneChild’sDetailsFullNameDateofBirthParent/GuardianContactContact:Telephone:E-mail:ContactviaSchoolonlyPleasesupplyacurrentphotographofthechildandgivetotheschoolorcaterer.
Alternatively,attachaphotographtotheemailwhenyousendthisform.
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MenuPlanning
Thismenuwillbeplannedaroundeliminatingthereportedallergen/s.Themenuwillbenutritionallybalancedwherepossibleandasclosetothestandardmenuasthedietwillallow.TheNorsekitchensarenut freeenvironmentsandwetakeeveryprecautiontoeliminatecrosscontaminationwithallallergens.However,wecannotguarantee100%allergenfree.Lunchrequiredallweek:YesNoIfnostateoccasionswhennotrequired:MENUREQUIREMENTSPleaseindicatetheFood(triggers)tobeexcludedfromthemenu:
Gluten Wheat
Milk Eggs Fish Soya Otherfoods:
Pleasegiveabriefdescriptionofsymptoms:Injectabletreatmentrequiredinanemergency:YesNoCarePlaninPlace:YesNo
GPorotherHealthProfessionalandParents/GuardianssignatureIcanconfirmthatthischildneedstoexcludethefoodsindicatedabove.Thisisdueto:Surgery/HospitalGP/HPSignaturePrintNameParent/GuardianSignatureNorseRepThisdocumentisconfidentialandacurrentcopyshouldbekeptwiththechild’scareplanwiththelatestmenu.Acopyofthemenuandcurrentphotographwillbekeptintheschoolkitchen.
Pleaseemailthiscompletedformto:[email protected]