This form is used for students who have medically documented severe allergies/reactions to foods that affect one or more of the child's major life activities such as anaphylaxis, problems eating, swallowing, digesting or breathing.
A licensed medical authority must complete and sign this form before substitutions can be made at school. A licensed physician, physician assistant, or certified nurse practitioner are able to complete the form.
This form MUST contain the following information:
The child's disability
How the disability restricts the diet
Major life activity affected
Foods to be omitted
Foods to be substituted
Signature from licensed medical authority
This form is used for students who have non-severe allergies such as hives or a rash when ingesting foods. The school is not required to accommodate these requests, but we will address each request on a case by case basis. These requests can often be managed with Offer vs. Serve with the student choosing only those foods he/she can eat safely.
A Special Diet Statement for a Child WITHOUT a Disability can be signed by a licensed physician, physician assistant, certified nurse practitioner, registered dietitian, licensed nutritionist, or chiropractor.
All substitutions must meet all USDA meal pattern requirements.