Special Diet Verification Form

At The Club Dining Facility, we are happy to meet the needs of our students who may have allergies or other needs regarding the food we serve. Please note that vegetarian and gluten free options are served at every meal.

Learn More About Our Special Diets

If you are vegetarian you do not need to fill out the special diet form, see our dinning manager if you have questions. Diners with food allergies are expected to be responsible about their diets to promote safety and minimize the risk of a reaction. The poster below helps you to identify the most common food allergens: Please follow the steps below. Step 1: Complete the form below.


Step 2: Schedule a meeting with the Counseling and Disability Services Director in McKy 181.
Contact the Director of Counseling and Disability Services ( Disability Coordinator ) Leilani Auna L.C.S.W. in Mcky 181
or call 808 675-3518 to schedule an appointment.
The student agrees that it is his/ her responsibility to share all pertinent information about their special dietary needs and is responsible for what they eat.
The Counseling and Disability Services will inform the Dining Facility Manager of the student’s special dietary needs and will provide any documentation from the student’s Physician.

Step 3: Schedule a meeting with the Club Dining Manager.
Setup an appointment to visit with the Dining Club Manager, Marilou Lee, Monday – Friday between the hours of 8:00am – 4:00pm
via email at Marilou.lee@byuh.edu
She will also schedule a meeting with the Executive Chef to discuss menus options and to setup a special dietary program for you until you have finished your paperwork with the Counseling and Disability Services.(step 2).


Terms & Agreements

Photo Taken
- With the customer’s permission, his/ her photography will be taken and posted on the special dietary student meal board so the kitchen crew can determine the specific diet the customer requires.
Dietary Information
-As a student requesting a Special Dietary needs, I hereby consent to discuss my medical condition with the Dining Facility Manager, the Executive Chef, and the Counseling Services Coordinator. -I understand that any discussion or documents provided by me will be stored by BYU Hawaii according to law and current regulations.
6 + 4 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.