Meal request form for ill CSB students on a CSB Campus Meal Plan

Please complete the form below to request meals for pick up due to illness. This request will be filled as indicated below. Should you feel better and wish to end the ill student meal service you need to call and cancel any remaining meals at 320-363-5112.

Please order 2 hours ahead of time, if possible. Shorter notice is permitted, but may mean a longer wait. Orders may take a minimum of 20 minutes to prepare. Guests may also order by calling 320-363-5112.

Pick up is required, please indicate the name of the person on this form who will most likely be the one to pick up your order. Please pick up the meal requested at the Gorecki Dining Center Cashier station.

If you are ordering a meal at 4pm or later for the same day's evening meal, please call the register at 320-363-5112 to order.

Name (First and Last)

Email Address

Banner ID #:

Residence Hall (Select From List Below)

Room Number

Phone Number (Please include area code. i.e. 012-345-6789):

Select your RD from the list below (this sends your request directly to them):

Click in the box below and enter the date you are requesting a meal(s)

Please complete a separate form for each day you are requesting meals

Please keep in mind Culinary Services needs at least a 2 hour lead time to prepare a meal from this form. If you require a meal with less than 2 hours notice, please call 320-363-5112.

Meals Needed: Please select one meal period

Breakfast Lunch Dinner

Sick Meal

Please select the items you are requesting:

	Chicken Broth (12 oz)		Applesauce (1 cup)
	Vegetable Broth (12 oz)		Gatorade
	Crackers (2 packets) (2 in each packet)		Apple Juice
	Rice (1 cup)		Other whole fruit:
	Banana (1)		Other whole fruit:

Quarantine/Isolation Meal

If you are quarantining/isolating due to possible illness or exposure, you may instead select from these meal options below:

	Non-vegan Hot Meal Home cooking (or Grill) entrée, Starch+ Vegetable Side, Fruit Side
	Non-vegan Cold Meal Salad or Sandwich, Vegetable side, Fruit side
	Vegan Hot Meal Granary (or Grill vegan) entrée, Starch+ Vegetable side, Fruit side
	Vegan Cold Meal Salad or Sandwich, Vegetable side, Fruit side

*Menu subject to change depending upon availability*

Pick up Time and Location:

Breakfast:

Monday-Sunday 9:00am - 9:30am at the Gorecki Cashier Station

Lunch:

Monday-Sunday 11:00am - 11:30am at the Gorecki Cashier Station

Dinner:

Monday-Sunday 5:00pm - 5:30pm at the Gorecki Cashier Station

Please choose the appropriate option from the list below:

	I live on campus in the Residence Halls and have a full meal plan.
	I live in the campus apartments or off campus and have an apartment plan - please deduct the cost for all meals from my Bucks.
	I live in the campus apartments or off campus and have an apartment plan- please deduct a meal pass for each meal selected from my plan.

Name of person(s) most likely picking up your meals:

Please list any allergies:

Forms Manager

Meal request form for ill CSB students on a CSB Campus Meal Plan

Meals Needed: Please select one meal period