Medical Statement Template For Students With Special Nutritional Needs For School Meals - Ucps School Nutrition Services
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2UCPS School Nutrition Services
407 N. Main St. Suite 100, Monroe, NC 28112
Medical Statement for Students with Special Nutritional Needs for School Meals
Ori gi n al to Sch ool N u t ri tion
Cop y to T ea ch er
Cop y to Sch ool N u r s e
When completed fully, this form gives schools the information required by the U.S. Department of Agriculture (USDA), U.S. Office for Civil
Rights (OCR), and U.S. Office of Special Education and Rehabilitative Services (OSERS) for meal modifications at school. See “Guidance for
Completing Medical Statement for Students with Special Nutritional Needs for School Meals” for help in completing this form.
PART A
(To be completed by Parent/Guardian)
Name of Student: (Last) ___________________
(First) _______________________
(Middle) ____
Date of Birth _________
Student ID # __________ School ___________________
Grade ______
Will student eat breakfast provided
Will student eat lunch provided
Will the student eat a snack provided
by the school cafeteria?
by the school cafeteria?
by the After School Snack Program?
Yes No
Yes No
Yes
No
Printed Name of Parent/Guardian: ____________________________________________________________
Mailing Address: _________________________
City: ________________
State/Zip: __________
Phone number(s): ____________________
______________________
_____________________
(Work)
(Home)
(Cell)
Email Address: ________________________
What concerns do you have about your student’s nutritional needs at school?
What concerns to you have about your student’s ability to safely participate in mealtime at school?
Does the student have an identified disability and an Individualized Education Program (IEP) or 504 Plan?
Yes No
If Yes and you have concerns about nutritional needs, have a licensed physician complete Part B, page 2, of this form and
sign it. Return completed form to _____________________________________________.
If No and you have concerns about nutritional needs, have a licensed physician or recognized medical authority complete
Part B, page 2, of this form and sign it.
Return completed form to _____________________________________________.
NOTE: Special dietary needs for students without an IEP or 504 Plan are accommodated at the discretion of
the Child Nutrition Administrator and policies of the school district.
Parental/Guardian Consent: I agree to allow my child's health care provider and school personnel to discuss
information on this form.
Parent/Guardian Signature: _______________________________________
Date:_____________
“USDA is an equal opportunity provider and employer.”
Department of Public Instruction Child Nutrition Services
N.C.
Revised
9/20/13
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