Dietary Restrictions & Substitutions Statement Form

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Dietary Restrictions & Substitutions Statement
The following statement is for United Stated Department of Agriculture (USDA) programs,
including the Child and Adult Care Food Program.
USDA regulations 7CFR Part 15B requires substitution or modifications in school/program meals for children whose
disabilities (defined below) restrict their diets. A child with a disability must be supplied substitutions in foods when that
need is supported by a statement signed by a licensed physician. Food allergies which may result in severe, life-threatening
(anaphylactic) reaction, also meet the definition of “disability”, and the substitutions prescribed by the licensed
physician/medical authority would be made.
“Disability”: A physical or mental impairment which substantially limits one or more of an individual’s major life
activities.
“Major Life Activity”, as defined by ADAAA: caring for oneself, performing manual tasks, seeing, hearing, eating,
sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking,
communicating, working, and major bodily functions.
“Major Bodily Functions” has been defined as: functions of the immune system, normal cell growth, digestive,
bowel, bladder, neurological, brain, respiratory, circulatory, cardiovascular, endocrine, and reproductive functions.
The statement must include the following:
To be completed by Parent/Guardian
Child’s Name: ________________________________________________
Date of Birth: ____________
Parent/Guardian Name: _________________________________________
Address: _____________________________________________________
_____________________________________________________
Phone Number: (Home) _________________ (Work) _________________
Parent/Guardian Signature: ______________________________________
Date: ________________
To be completed by child’s Physician or Medical Authority:
State the “disability” and major life activities affected:
_________________________________________________________________________________________
_________________________________________________________________________________________
List the food allergies or food intolerances:
List the food or beverages to be substituted:
___________________________________
____________________________________
___________________________________
____________________________________
___________________________________
____________________________________
List any additional dietary restrictions or special diet:
_________________________________________________________________________________________
_________________________________________________________________________________________
Physician’s Name: _________________________________________
Office Number: _______________
Physician/Medical Authority Signature: _____________________________
Date: _________________
*Please have parent/guardian review form annually and initial/date if no changes are required.
*Any changes require submission of a new form signed by the child’s physician or medical authority.

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