Dietary Restriction Form

Student's Name*

Grade

School

Parent/Guardian Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Student has a disability which requires a special meal or accommodation. (Refer to definitions on reverse sideof this form.) A licensed medical physician must sign this form.Student does not have a disability, but is requesting a special meal or accommodation due to foodintolerance(s) or other medical reasons. Food preferences are not an appropriate use of this form. Schoolsand agencies participating in federal nutrition programs may accommodate reasonable requests. A licensedmedical physician, physician’s assistant, registered nurse, nurse practitioner, or registered dietitian must signthis formThe student does not have a disability. A fluid milk substitution is being requested for the student. Schools andagencies participating in federal nutrition programs may choose to accommodate this request by providing aUSDA approved fluid milk substitute. A licensed medical physician, physician’s assistant, registered nurse,nurse practitioner, registered dietitian, parent, or guardian must sign this form.

State the disability or medical condition requiring a special meal, accommodation, or fluid milk substitute.*

ie. Dairy allergy, peanut allergy, Celiac disease...

If student has a disability, provide a brief description of the major life activity affected by the disability.*

ie. respiratory failure, confusion...

Diet prescription and/or accommodation: (Please describe in detail to ensure proper implementation.)*

ie. No dairy, No nuts...

RegularChoppedGroundPureed

Foods to be Omitted

Foods to be Substituted

Any adaptive equipment needed:

Signature of parent/guardian*

Date