Simple Zone Access Request

*Documentation is required for filling out this form* Prior to filling out the form please have your medical documentation available to submit. Documentation must include specific allergy or intolerance information.

Simple Zone is a pantry where food items can be housed with precautions against cross-contact. This space is reserved for students with food allergies/intolerances/sensitivities or Celiac disease and includes foods prepared without gluten, peanuts, and tree nuts.

Name (As entered in UNewHaven system) Name (As entered in UNewHaven system) First Last
If you have a preferred name and/or pronouns, please enter them here.
Student ID Number
Phone Phone - ### - ### ####
UNewHaven Email Address
Specific Food Allergy/Dietary Needs (Example: Allergic to peanuts)
Which University meal plan do you currently have?

Which University meal plan do you currently have? Charger Pride (21 meal swipes per week + dining dollars) Charger Gold (16 meal swipes per week + dining dollars) Charger Blue (11 meal swipes per week + dining dollars) Senior Meal Plan (7 meal swipes per week + dining dollars) Green Plate (80 meal swipes per semester) Gold Plate (60 meal swipes per semester) Blue Plate (30 meal swipes per semester)
I give consent to the University of New Haven Dining Services, Accessibility Resource Center (ARC), and the Campus Card Office to discuss my dietary needs to best provide support.

I give consent to the University of New Haven Dining Services, Accessibility Resource Center (ARC), and the Campus Card Office to discuss my dietary needs to best provide support. Agree
I understand that Simple Zone foods are prepared using ingredients that do not contain peanuts, tree nuts, and gluten. However, Simple Zone is located in a facility that also prepares foods with these allergens. University of New Haven Dining Services takes measures to eliminate allergen and gluten cross-contact, but there may be the rare possibility of cross-contact with other foods.

I understand that Simple Zone foods are prepared using ingredients that do not contain peanuts, tree nuts, and gluten. However, Simple Zone is located in a facility that also prepares foods with these allergens. University of New Haven Dining Services takes measures to eliminate allergen and gluten cross-contact, but there may be the rare possibility of cross-contact with other foods. Agree
By submitting this request, I understand that once approved, I must meet with the Registered Dietitian and University Dining Services prior to first use, and that I will need to renew my request at the beginning of each academic year that I am enrolled.

By submitting this request, I understand that once approved, I must meet with the Registered Dietitian and University Dining Services prior to first use, and that I will need to renew my request at the beginning of each academic year that I am enrolled. Agree
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