Adopted: November 2018
In accordance with District Regulation 710.2.4AR (Meal Substitution Requests), the school district will make reasonable substitutions to school meals on a case-by-case basis for students who are considered to have a disability that restricts their diet.
· Parents, guardians or adult students wishing to request reasonable substitutions to school meals based on a disability should return this completed form to the school nurse.
· This form must be signed by, or supported by a signed written statement from, a licensed physician, physician assistant, or an advanced practice registered nurse, such as a certified nurse practitioner.
Once the form is submitted, the school’s Food and Nutrition Manager may contact you to discuss the request in more detail. The information you supply on this form is subject to the “Notices” section below.
Student’s name Date of birth
Name of school/program attended
Home phone number Work phone number
Dietary Accommodation (Must be completed or verified by a licensed physician, physician assistant, or an advanced practice registered nurse, such as a certified nurse practitioner.)
· State the allergen or food to be avoided
· Brief explanation of how exposure to this food affects the student
· List specific foods to be omitted and substituted. Attach a sheet with additional instructions as needed. (The school district is not required to provide the exact substitution or modification requested but will work with you to offer a reasonable modification that effectively accommodates the student’s disability.)
Foods to be Omitted
Foods to be Substituted
Please provide any additional information you would like the school to know:
Health Professional Signature: I have completed or verified the above dietary accommodation information.
Name (print) ______________________________ Title/credentials
Phone number ___________________________ Email ______________________________ Date _________
Parent/Guardian/Adult Student Signature
Signature _________________________________________________________ Date ____________________
Optional Authorization: You may authorize relevant district staff to clarify this form with the health professional identified above by signing the following Optional Authorization section:
In accordance with the provisions of the Health Insurance Portability and Accountability Act (HIPPA) of 1996 and the Family Educational Rights and Privacy Act, I hereby authorize the above-identified health professional to release such protected health information as is necessary for the specific purpose of providing special diet information to District 196 staff with a legitimate need to know such information and I consent to allow the health professional and District 196 to exchange information relating to my student’s special dietary needs, which—I acknowledge—may include information deemed private educational data on my student. I understand that permitting the sharing of such information may assist District 196 staff in assessing and accommodating the student’s dietary needs, but that I am not obligated to sign this authorization. I understand that declining to sign this authorization does not impact my ability to request a reasonable meal substitution and that the district will still consider my request. I understand that permission to release this information may be rescinded at any time except when the information has already been released.
Parent/Guardian/Adult Student signature _______________________________ Date ______________
Notices: Information provided on this form will be used to determine if your student is eligible for reasonable substitutions to meals based on a disability. Except as otherwise permitted by law or required by a subpoena or court order, information supplied on this form will only be shared with District 196 staff with a legitimate need to know such information (such as the school nurse and Food and Nutrition staff involved in assessing and accommodating meal substitution requests). You are not obligated to provide the information on this form, but if you do not do so, the school district may not be able to offer a reasonable meal substitution to your student.
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the school district is prohibited from discriminating based on based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). For more information, including details about alternative means for receiving program information, please visit: http://www.district196.org/about/departments/food-and-nutrition-services/
References: - Administrative Regulation 710.2.4AR, Meal Substitution Requests