1.  School/Agency 2. Site 3.  Site Manager & Telephone Number
4.  Name of Student 5.  Age or Grade
6.  Name of Parent or Guardian 7.  Telephone Number

8.  Check One Box:    Student has a disability which requires a special meal or accommodation.  (Refer to definitions on reverse side of this form.) A licensed Medical Physician (M.D.), Physician Assistant (P.A.), Osteopathic Physician (D.O.), Advance Practice Registered Nurse (A.P.R.N.), Naturopathic Physician (N.D. or N.M.D.) must sign this form.

Student does not have a disability, but is requesting a special meal or accommodation due to food intolerance(s) or other medical reasons. Food preferences are not an appropriate use of this form. Schools and agencies participating in federal nutrition programs may accommodate reasonable requests. A licensed medical physician, physician’s assistant, registered nurse, nurse practitioner, or registered dietitian must sign this form.

The student does not have a disability. A fluid milk substitution is being requested for the student. Schools and agencies participating in federal nutrition programs may choose to accommodate this request by providing a USDA approved fluid milk substitute. A licensed medical physician, physician’s assistant, registered nurse, nurse practitioner, registered dietitian, parent, or guardian must sign this form.

9. State the disability or medical condition requiring a special meal, accommodation, or fluid milk substitute.
10. If student has a disability, provide a brief description of the major life activity affected by the disability.
11. Diet prescription and/or accommodation:  (Please describe in detail to ensure proper implementation.)
12.  Indicate texture:                               Regular                Chopped                Ground                Pureed
13.  Specific foods to be omitted and substituted.  You may attach a sheet with additional information.
A.   Foods to be Omitted: B.    Foods to be Substituted:
   
   
   
   
14.  Adaptive Equipment Needed:
15.  Signature of Preparer 16.  Printed Name 17.  Telephone Number 18. Date

19.  Signature of Medical Authority

and Credentials

20.  Printed Name 21.  Telephone Number 22. Date

23. To be completed by the LEA/School:       Additional information needed             Approves request             Denies request

LEA Comments:

16-17_Special_Dietary_Needs_Request_Form.pdf

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