Please complete and provide electronic signature below.  Completed forms requesting special meal accommodations are reviewed by the Registered Dietitian and HPU Hospitality management team.  Your request will be reviewed and you will be contacted to discuss your request further.  For additional information or questions, please contact the Registered Dietitian.
Registered Dietitian
Please supply a cell or other phone number where we can best reach you.
Please explain the reasons for your special meal accommodations request:
Please indicate the specific accommodations you are requesting:
Please select how you would like to be contacted by HPU Dining:
Please tell us what we are missing.  What else would you like us to know, so that we can better serve you?
Authorization for Release of Confidential Information:
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 form the Dean of Students Office, Campus Health Services, and/or Accessibility Services.
Please type in your first and last name as having read and understood this release authorization.