1. School or Agency: Print the name of the school or agency that is providing the form to the parent.
Site: Print the name of the site where meals will be served.
3. Site Phone Number: Print the phone number of site where meal will be served.
4. Name of Child or Participant: Print the name of the child or participant to whom the information pertains.
Age of Child or Participant: Print the age of the child or participant. For infants, please use date of birth.
6. Name of Parent or Guardian: Print the name of the person requesting the child or participant’s medical statement.
7.Phone Number: Print the phone number of parent or guardian.
8. Description of Child or Participant’s Physical or Mental Impairment Affected: Describe how the physical or mental impairment restricts the child or participant’s diet.
9. Explanation of Diet Prescription and/or Accommodation to Ensure Proper Implementation: Describea specific diet or accommodation that has been prescribed by the state healthcare professional.
10. Indicate Texture: If the child or participant does not need any modification, check “Regular”.
11. Foods to be Omitted: List specific foods that must be omitted (e.g., exclude fluid milk Suggested Substitutions: List specific foods to include in the diet (e.g., calcium-fortified juice
12. Adaptive Equipment to be Used: Describe specific equipment required to assist the child or participant with dining (e.g., sippy cup, large handled spoon, wheel-chair accessible furniture, etc
15. Phone Number: Phone number of state licensed healthcare professional.
16. Date: Date state licensed healthcare professional signed form.
13. Signature of State Licensed Healthcare Professional: Signature of state licensed healthcare professional requesting the special meal or accommodation.
14. Printed Name: Print name of state licensed healthcare professional.