Special Meals Prescription Form Page 3
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3SAFE EATING PLAN
(To be completed by Special Education Team or 504 Coordinator)
Describe any special positioning
needed while eating/drinking:
Provide safe eating environment by:
Peanut Free Table
Describe any special utensils or
Quiet Table/Area
feeding equipment needed:
Other:
Describe any special methods for
presenting food/drink:
Liquids served, check all that apply:
bottle
sippy cup
spoon
with straw
juice box holder
other:
PHYSICIAN/MEDICAL AUTHORITY SIGNATURE SECTION
I certify that the above named student needs special meals prepared as described above because
of the student's disability.
I certify that the above named student would benefit from special meals as described above, however this
child is not disabled. It is up to the discretion of each school/institution if and for what conditions they will
provide substitutions.
Physician's/Medical Authority's Signature
Office Phone Number
Date
_________________________________
Physician's/Medical Authority's Printed Name
PARENT/GUARDIAN SECTION
YES Parent/Guardian accepts accommodations offered and his/her child will be participating in the Child
Nutrition Program or any other program offered within the child's institution.
Snack
Breakfast
Lunch
Dinner
NO
Parent/Guardian declines accommodations offered and his/her child will not be participating in the
Child Nutrition Program or any other program offered within the child's institition.
__________________________________________
Parent's/Guardian's Signature
Date
cc:
Parent/Guardian
Physician
Nutritionist
Feeding and Swallowing Specialist
Food Service Director
School Nurse
School Principal
Special Ed Coordinator
For Official Use: Date returned to the Special Ed coordinator at the District Office:
Date
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