Allergy & Dietary Restrictions Form

For Child Cares & Schools

Your Centre Name *

Service Type *

Region (for YMCA centres only)

Your Name (Staff) *

Your Email Address *

Please use the

Snack Club Allergy & Dietary Restrictions Form!

Would you like more than one email to receive a confirmation?

Yes I have other people who should receive a confirmation.

Who is your RFRK client experience coordinator? *

What can we do for you today? *

ADD a child to the Allergy Program

UPDATE a child's existing allergy profile

REMOVE a child permanently from the Allergy Program

SUSPEND a child temporarily from the Allergy Program

TRANSFER a child's existing allergy profile to another centre

Child/Staff Name (First and Last)
(Note: for Allergy Removals, Suspensions, and Transfers you can enter multiple names if the request is the same for all children/staff)
*

What would you like to update for this child? (please check all that apply) *

Allergy Program Registration Dates (as indicated below)

Age Group

Enrolled During these Days of Week

Meal Type Enrollment (AM/Lunch/PM)

Allergies/Dietary Restrictions

List the specific dates that this child/staff will not be in attendance:
(We will cancel the substitutes that were scheduled for this individual during these dates. We require at least 3 full business days notice to suspend their profile.) *

Desired Start Date
(Note: at least 4 full business days' notice is required, forms submitted after 4 pm are processed the next business day) * 🛈 +

Desired End Date
Not Required, but you may enter an end date if you know the last day this child will be at your centre (example: temporary transfer to your centre).
+

Do you have any upcoming picnics?

Yes

No

N/A (my centre does not order picnics)

LAST DAY you require allergy substitutes scheduled for this child/staff
(Note: at least 4 full business days notice is required, forms submitted after 4pm are processed the next business day)
* 🛈 +

Since this is an allergy addition, please enter the date(s) of the picnic(s) that this child/staff will now be attending

Please note: Picnics can only be adjusted within 5 business days

*

Since this is an allergy update, please enter the date(s) of the picnic(s) that this child/staff will be attending.

Please note: Picnics can only be adjusted within 5 business days *

Do you want us to ADD an extra portion to the picnics listed above to account for this new child?
Please note: Picnics can only be adjusted within 5 business days
*

Yes

No

Since this is an allergy removal, please enter the date(s) of the picnic(s) that this child/staff will no longer be attending
Please note: Picnics can only be adjusted within 5 business days *

Since this is an allergy suspension, please enter the date(s) of the picnic(s) that this child/staff will no longer be attending *

Do you want us to REMOVE a portion from the picnics listed above to account for this child? Please note: Please note: Picnics can only be adjusted within 5 business days *

Yes

No

Note for Transfers: The child's AGE GROUP and DIETARY RESTRICTIONS from the original centre will be transferred as is to the new centre.

Please let us know how we can set up their days enrolled and meal type at the new centre:

Desired Date You Want the Transfer to Start
(Note: at least 4 full business days notice is required, forms submitted after 4pm are processed the next business day)
* 🛈 +

*

	Centre Name
Child is leaving (i.e. remove child from this original centre):	Centre Name
Child is moving to (i.e. add child to this new centre):	Centre Name

Enrolled during these Days of the Week *

Desired End Date When You want this Transfer to Stop
Not required, but you may enter an end date if this is a temporary transfer to the new centre (i.e. the child will return to the original centre)
+

Meal Type Enrollment (select all that apply) *

AM Snack

Lunch

PM Snack

Form Completed! Please click 'Next' to submit!

Kimberly	Leticia	Patrick	Russell
Sabrina	Hannah