Submit your Parent Food Allergy/Issue Questionnaire to Blue Rill Day Camp, serving Rockland and Bergen Counties and Manhattan

Blue Rill is very aware of the increasing number of children with food allergies and our goal is to provide a safe and successful summer experience for all campers. To help us keep track of your child’s individual needs and keep your child safe throughout the summer, we have put together a questionnaire for areas where food allergy questions may arise. Please fill out the form to the best of your ability.

Camper's First and Last Name:	*
Parent’s First and Last Name:	*
Best phone number to reach you during camp hours:	*
Email:	*
General Information
What is your child sensitive or allergic to?
Please describe possible reactions to the allergens:
Does your child have an Epi-Pen?	Yes No
Over the past year, has your child outgrown any allergies or developed new ones?	Yes No If yes, please explain:
Have their reactions gotten better or worse? If so, please explain.
In regards to your child’s food allergies, can your child eat foods with labels that state:	a) manufactured in a facility made with... Yes No b) made on same equipment as... Yes No c) may contain traces of... Yes No
Lactose Intolerance: If your child is lactose intolerant, what are his/her needs (ex. Needs pill before eating any dairy, can’t eat any dairy, can eat certain foods). Please explain:
Lunch For your review, there is a list of all available lunch and snack bar choices on our Lunch and Snacks Info page. In addition, an ingredient list of all lunch, snack bar snacks and ice cream/ices is available upon request. Would you like to receive this information prior to the first day of camp? Yes No
Does your child need any special arrangements at lunchtime?	Yes No If yes, please give specific details:
Snacks - AM & PM All campers are offered ice cream and/or ices in the afternoon. Are camp ice pops and/or ice cream snacks OK for your child if the label does not list any of your child’s food allergies? Ice Pops Ice Cream Both If your camper is a Sprout, is the morning snack of Nabisco graham crackers (Kosher/D) and Mott’s apple juice ok? Yes No Cooking Program: All campers participate in our cooking program. The cooking staff does its best to adjust the recipes as needed and create a safe version for campers with food issues. Nuts are not used in our recipes and ingredients are checked to make sure there are no nuts listed in any way. Depending on each recipe, you can choose to either provide a safe duplicate or alternate snack the morning of cooking or we can use one of your snacks already at camp or use Blue Rill’s safe snack choice. The cooking counselor may be able to make a safe version of the recipe substituting what your child is allergic to in the morning prior to cooking (i.e., using soy products instead of regular dairy products). Can your child eat the safe version? Yes No Can camp can provide a safe snack (ex. Wise or Lays potato chips, animal crackers, Cheez-its) if there is no available recipe alternative? Yes No Would you like to receive a copy of our 2010 Cooking Program recipes in June? Yes No
Birthday Treats & Parties If another camper brings in a birthday treat, can your child eat it if we check it? Yes No Or do you need to be called? Yes No Can your child eat Dunkin’ munchkins? Yes No Can your child eat Dunkin donuts? Yes No (Dunkin’ Donuts now states they can’t guarantee nut free.) Would you like to provide safe snacks to keep in the nurse’s office in case your child can’t eat a treat that is brought in for birthdays, group parties or other food activities? Yes No Can camp can provide a safe snack (ex. Wise or Lays potato chips, animal crackers, Cheez-its) if there is no available snack? Yes No
Additional Comments: