Instructions: Complete and provide electronic signature below. Completed forms requesting special meal accommodations are reviewed by the Registered Dietitian and Carolina Dining Services management team. Student Information First Name* Last Name* PID* Address 1* Address 2 City* State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip* Phone Number* Email Address* By signing below, I certify that I have read the Allergen Booklet: Carolina Dining Services Guide to Managing Food Allergies and agree to personal management/responsibilities, and understand CDS commitment and communication disclaimer. Please explain the reason for your special meal accommodations request* Please indicate the specific accommodations that you are requesting* I hereby give my permission for the release of my special meal accommodations request form, which verifies the existence of special dietary needs such as a food allergy or intolerance, to the Department of Housing and Residential Education and appropriate personnel from the Dean of Students Office, Campus Health Services, and/or Accessibility Services.* Student Signature * Date Thank you for your submission. Your form will be reviewed and you will be contacted to discuss your request further. For additional information or questions, please contact the Registered Dietitian at 919.962.2352.