Medical Statement For Participants Requiring Food Substitutions - Arizona Department Of Education
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1State of Arizona
Department of Education
CHILD & ADULT CARE FOOD PROGRAM
MEDICAL STATEMENT FOR PARTICIPANTS REQUIRING FOOD SUBSTITUTIONS
Name of Participant:
Date of Birth:
Parent Name:
Parent Telephone Number:
Name of Center:
Telephone Number of Center:
Address of Center:
Dear Parent/Guardian:
This day care center participates in the Child and Adult Care Food Program (CACFP) and must serve meals and snacks
meeting the CACFP requirements. Food substitutions may be made only when supported by a recognized medical
authority. A recognized medical authority may include, but is not limited to a medical physician, registered nurse, or
registered dietitian. The recognized medical authority must specify, in writing, an indication of the medical or other
special dietary condition which restricts the participant’s diet; the food to be omitted and the food or choice of foods that
may be substituted. Please have a medical authority complete and sign this form. Return it to the center director upon
completion.
1. Identify the medical or special dietary condition which restricts the participants diet:
The participant has the following disability as defined under Section 504 of the Rehabilitation Act or Part B of IDEA
which requires food substitutions: ____________________________________________________________________
_______________________________________________________________________________________________
The participant has the following food allergy that may result in a severe, life-threatening (anaphylactic) reaction which
therefore meets the definition of a disability and requires food substitutions: ___________________________________
_______________________________________________________________________________________________
The participant has the following food intolerance which does not meet the definition of a disability but it is preferred that
certain foods be avoided: __________________________________________________________________________
_______________________________________________________________________________________________
2. Explain why the disability restricts the diet and the major life activity affected by the disability:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
□
N/A Participant is not disabled
3. List the food or foods to be omitted from the diet and the food or foods that are to be substituted:
Additional instructions, requirements,
Foods to be omitted
Allowable Substitutions
or
modifications
(such as
special
equipment, texture, thickness, etc.)
4. Certify that the participant must be provided the special diet or accommodations indicated above:
Printed Name
Title
Signature
Date
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