Special Diet Registration Form Jan 2018 - Norse...

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SpecialDietRegistrationForm

TocompletethisformonlinepleasedownloadandsavethisPDF,completeall fieldsande-mailtoalison.parker@ncsgrp.co.uk

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:alison.parker@ncsgrp.co.uk