Purpose: To ensure the safety and well-being of the participant by documenting specific dietary restrictions, medical conditions, and required medication administration.
Full Name
First Name
Middle Name
Last Name
Date of Birth
ID Number (if applicable)
Emergency Contact Name
Emergency Contact Phone
Please check all that apply and provide specific details regarding the severity.
Category | Specific Requirements/Allergen | Severity/Reaction | |
|---|---|---|---|
Food Allergies (e.g., Peanut, Prawn) | |||
Intolerances (e.g., Lactose, Gluten, Fructose) | |||
Religious/Ethical (e.g., Halal, Kosher, Vegan) | |||
Texture/Safety (e.g., Pureed, Soft foods, Low sodium) |
Crucial Note: Does the participant carry an epinephrine auto-injector (e.g., EpiPen)?
Please list all medications that must be administered or monitored during the program/event duration.
Medication Name | Purpose/Condition | Dosage (e.g., 5mg, 2 puffs) | Frequency (e.g., Daily, As needed) | Specific Time(s) | ||
|---|---|---|---|---|---|---|
1 | ||||||
2 | ||||||
3 | ||||||
4 | ||||||
5 |
Self-Administration: Is the participant capable of self-administering this medication?
Storage Requirements: Does any medication require refrigeration or specific storage?
Provide any additional information regarding symptoms to watch for, behavioral triggers related to diet/medication, or specific protocols for a medical emergency.
Additional Notes
I certify that the information provided above is accurate and complete to the best of my knowledge.
I authorize the designated staff to provide the indicated dietary accommodations and, if necessary, assist with or monitor the administration of the listed medications.
Signature of Participant/Guardian
Physician Signature
Form Template Insights
Please remove this form template insights section before publishing.
The most significant insight into this form is the holistic view of the participant. Many organizations treat dietary needs and medical needs as separate silos. However, this form recognizes that:
The form follows a "Severity-First" logic.
By specifically asking for Dosage and Frequency, the form moves away from "anecdotal" care to "clinical" care.
From a user experience (UX) perspective, this form acts as a trust-building tool.
The form is designed to eliminate "assumption-based" care.
Because the form is designed for an online environment, the data captured is structured. This means:
Mandatory Questions Recommendation
Please remove this mandatory questions recommendation before publishing.