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Critical Diet Request Form

Nut Allergy
 Where various ingredients are removed due to allergy
 

Nut Allergies: Nuts are not used in catering where a group advises a nut allergy.  All care is taken to avoid the use of nuts or nut traces when advised of an allergy, however it is not possible to guarantee that certain ingredients used will have been prepared on premises that carry nuts or have traces of nut products contained in them.  Further it cannot be guaranteed that other guests will not bring in nuts in their own snacks.  People with severe nut allergies need to be aware of this disclaimer, and their responsibility to always carry their own medication.
 
  
Full Name:
Name of Group you are attending with:
Dates of your stay:   until 
The person in charge of your group:
Your age:  Phone:


Please list in detail your dietary restrictions, either by clearly stating the limited foods you can eat, OR the restrictions on foods you cannot eat: whichever is easiest to describe your diet.  (If you require specific brands of foods, please list understanding there will be an extra cost to supply).
I have an allergy to:
(Please tick all that applies)		 Brazil nuts
 Cashews
 Hazelnuts
 Macadamias
 Pecans
 Pine nuts		 Pistachios
 Walnuts
 Almonds
 Peanuts
All Nuts
I am ABLE to eat:
I am UNABLE to eat:
Is your allergy only when:
(Please tick what applies)		 You consume the nut
You consume the nut or when other around me have them
Are you able to have items that have been manufactured on equipment that may have been processed with nuts? Yes    No
What is the likely consequence of your diet not being met:

Mild         Serious         Potentially Fatal
Can you manage your own diet
(i.e. do not need supervision in selecting foods)?    

  Yes      No

 


Please note that Camp Clayton reserves the right to advise that they are unable to provide this special diet, where on assessing the request, they are unable to meet the requirements.  This will be advised by the Chef in Charge.  

Please add any further comment and information if required.  The Chef in Charge can be contacted on 6425 1893 during their rostered hours of work (please avoid calling at meal times).

 

 

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For a free brochure, email us on admin@campclayton.org.au
 and provide your mailing address.

Camp Clayton - 41 Clayton Road,
PO Box 3184, Ulverstone Tasmania  7315