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Allergen Form .pdf


Original filename: Allergen Form.pdf
Author: Beth Foley

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Allergen Information Form

At York Racecourse Hospitality we aim to cater for your dietary requirements which is why we kindly request for this form to be completed by anyone considering themselves
to have a dietary intolerance or allergy.
We understand that this information is sensitive and will therefore be issued only to the event team, operating chefs and environmental safety officer

Name of function attending: _____________________________ Date of function: ____________________________

Name: ________________________________________ ___

Date of Birth: _____________________________________

Address: ______________________________________________________________________________________________
Postcode: _______________________________________

Tel/ Mobile: ______________________________________

Email: __________________________________________

Date of Birth: _____________________________________

Why are we asking this? This information will be used to help medical officials
On 13th December 2014, new legislation (the EU Food Information for Consumers Regulation No. 1169/2011) came into force which requires food businesses to provide
allergen information. Under this legislation, if you have one of the 14 allergies listed below it’s our responsibility to understand our foods and guide accordingly.
However we cannot guarantee any of our foods do not contain traces of the 14 allergens as a majority of food is prepared in kitchens of which the
following allergens are also prepared and we understand there are different levels of allergen severity.
These 14 allergens are as follows:

1. Please detail the allergens relevant to yourself: ________________________________________________________________
2. Does your allergy cause anaphylaxis and require hospital treatment? YES / NO
Why are we asking this? In many cases allergies lead to anaphylaxis, in some cases they cause irritation, we need to understand the severity of your allergy.

3. Do you carry an Epi Pen for your allergy: YES / NO
- If YES, do you give permission for a York Racecourse/York Racecourse Hospitality first aider to administer it if required?
YES / NO (please delete)
Why are we asking this? In the event you require medical attention, our first aiders will require by law authorisation to administer an Epi Pen

4. Is your allergy airborne? YES / NO
Why are we asking this? In some cases allergic reactions can be triggered by allergens transported by air.
5. Please inform us of any further information you feel may be relevant in regards to your dietary requirement that may assist our staff
in ensuring you are well catered for: __________________________________________________________________________
______________________________________________________________________________________________________
Page 1 of 2

York Racecourse & York Racecourse Hospitality Standard Allergen Practices
Please read the below and sign once you have read and fully understood our standard allergen practices.
1. York Racecourse Hospitality will endeavour to accommodate all pre-notified dietaries, but cannot guarantee there will not
be traces of the 14 allergens listed above within our food.
2. At the event, you will make yourself known to one of the hospitality managers as soon as you arrive. These members
of staff can be identified by their green ties. If required, the manager will then discuss your requirements.
3. If you have a severe allergy and carry an Epi Pen, you will be served by one member of the team throughout your dining
experience. This particular member of the team will be introduced to you by one of our hospitality managers.
4. It is your responsibility to ensure you do not accept any dish from any other hospitality members other than the staff
member assigned to you.
5. York Racecourse Hospitality do not accept any liability for your actions at the event, or for any due diligence towards your
allergy that is contrary to our advice and recommendations. Nor do we accept any missing or misleading information that has
not been raised with us at least 72 hours prior to the event. We not accept any responsibility for lack of information
provided to us.
6. It is your responsibility to carry your epi pen during the event should your allergy require one.
7. In the unfortunate case that you do require medical treatment, we will use the information provided upon the completion of
this form to act as permission and guidance for any medical assistance by both our first aiders and the emergency medical
team upon arrival at York Racecourse.
If you have any further questions please do not hesitate to call our team on 01904 638971 or email:
events@yorkracecoursehospitality.co.uk

Sign: __________________________________________________

Date: ______________________________________

Print Full Name: _________________________________________

Next of Kin details:
Name: __________________________________________________

Relation: ___________________________________

Address: ______________________________________________________________________________________________
______________________________________________________________________________________________________
_________________________________________________________ Postcode: ___________________________________
Contact Number: ___________________________________________

Page 2 of 2


Allergen Form.pdf - page 1/2
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