Special Diets Allergy Forms

Students with special dietary needs must submit one of the following forms each school year. The form must be signed by a medical authority, which includes physicians, physician’s assistant, or a nurse practitioner. The completed form can be turned in at the school the student attends. Until a completed form is on file, parents/guardians are responsible for providing a lunch/breakfast for the student.

A student that has a food allergy or intolerance should have this form completed
 -  Medical Statement for Student Requiring Special Meals Due to Food Allergy or Intolerance.

A student with a disability that requires a special meal should have this form completed.
 -  Medical Statement for Student Requiring Special Meals Due to Disability.


Don’t know which form to fill out? Read the following definition of a disability if the student does not fall in the disability category you should use the medical statement for student requiring special meals due to food allergy and intolerance.

Definition of Disability
Under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA), a “person with a disability” means “any person who has a physical or mental impairment which substantially limits one or more major life activity, has a record of such impairment, or is regarded as having such an impairment.”

The term "physical or mental impairment” includes, but is not limited to, such diseases and conditions as:
 -  Orthopedic, visual, speech and hearing impairments
 -  Cerebral Palsy
 -  Epilepsy
 -  Muscular Dystrophy
 -  Multiple Sclerosis
 -  Cancer
 -  Heart Disease
 -  Metabolic diseases, such as diabetics or phenylketonuria (PKU)
 -  Food anaphylaxis (severe food allergy)
 -  Mental retardation
 -  Emotional illness
 -  Drug addiction and alcoholism

Major life activities covered by this definition include caring for one’s self, eating, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working.