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Food Item: _______________________________

First & Last Name: ____________________________

Class: ______________________________________

Check all that apply

Allergens Ingredients

❏ Dairy ❏ Meat (precise) _______________

❏ Soy ❏ Fish

❏ Wheat ❏ Spices
_____________________________

❏ Nuts ❏

❏ Eggs ❏

❏ Shellfish ❏

❏ Other ____________ ❏