Epi-Pen prescribed by your physician?
If yes, do you carry your Epi-Pen with you at all times?
Gluten Free Diet
Medical or Special Diet

Permission to share information? This form will be directed to Shavaun Cloran RD, at WPI Dining Services, Regina Roberto, Director of WPI Health Services, and Jillian Brooks, Nurse Practitioner of WPI Health Services

I give WPI Health Services and WPI Dining Services permission to share information about my food allergy to those personnel who can assist in my accommodations to the dining facilities at WPI. (required)