Food – Child Nutrition Services

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Special Dietary Modification Requests

To better serve our students with special dietary needs who require meal accommodations, please submit a medical statement to your school nurse using this Food and Child Nutrition Services Dietary Request Form .

A signature from both parent/guardian and a medical authority is required for sections A & B of the form or any combination of A & B with Section C. If the section of the form being filled out is only Section C , only a parent/guardian signature is needed and no medical authority signature is required.

Current USDA regulations no longer require annual updated medical statements from a medical authority. Therefore, any forms submitted will be valid until there is a request to modify or discontinue the request.

To CHANGE or MODIFY full or partial Existing Requests, it will require submitting another dietary request form and must have a signature from both parent/guardian and medical authority for Sections A & B. Section C only requires a parent signature.

To DISCONTINUE the Entire Request, it will require submitting another form but only a parent/guardian signature is needed for all Sections (A, B & C). A medical authority signature is not required to discontinue a request.

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