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Special Diet Form

Each special dietary request must be supported by a statement explaining the requested food substitution and must be signed by a recognized medical authority (Physician, Nurse Practitioner, Physicians’ Assistant). The Medical Statement must include:

1. An identification of the medical or other special dietary condition which restricts the child's diet 2. The food or foods to be omitted from the child's diet and the food or choice of foods to be substituted.

 If we do not receive a medical statement from a recognized medical authority, your child will receive a regular lunch tray. We will accommodate requests related to a disability that are not supported by a medical statement if the requested modifications can be accomplished within the Program meal pattern.  Click link below for diet prescription form.

Special Diet Form

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