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SPECIAL DIET STATEMENT Information requested on this form must be thoroughly completed and signed by a licensed physician or recognized medical authority and then submitted to the school/center/site before any meal modifications will be made in the United States Department of Agriculture Child Nutrition Programs. This form must be updated whenever the participanYs diagnosis or special diet changes. Special diet requests will be evaluated on a case-by-case basis. For a participant with a disability that restricts diet: Requests for a special diet must be supported by a statement of the disability and a diet order signed by a licensed physician. A school/center/site must comply with requests for special meals, food substitutions and/or any adaptive equipment. However, the school/center/site reserves the right to negotiate special food requests with the physician if product availability is a concern. For a participant without a disability who is medically certified as having a special dietary need: Requests for a special diet must be supported by a diet order signed by a recognized medical authority (licensed physician, physician's assistant, certified nurse practitioner, registered dietitian, licensed nutritionist or chiropractor). A school/center/site is encouraged to accommodate reasonable requests but is not required to do so. ParticipanYs Name: Last / First / Middle Initial Name of School/Center/Site Attended: ParenUGuardian Name: Parent /Guardian Address: City: Home Phone Number: Meals or snacks to be eaten at school/centerlsite: ci School: Center / Child Care: Breakfast Lunch Breakfast Lunch Supper Afterschool Care Program (snack) am / pm / eve Snack Afterschool Snack ParenUGuardian Signature: OR ParticipanYs Signature (Adult Day Care) State: Today's Date: Date of Birth: Work Phone Number: Zip code: all that apply) Site—Summer Food Service Program: Breakfast Lunch Supper Snack Date: NOTE to ParenUGuardian/Participant: In order to authorize the licensed physician to discuss or clarify this Special Diet Statement (if necessary) with the director of the school/center/site, you must also complete and sign the Voluntary Authorization Section at the end of this form. ❑ Participant has a disability and requires a special meal or food accommodation. A licensed physician must complete Questions 1-3 (below), Part 3 and Part 4 of this form before signing and dating this statement. Physician - please refer to the companion document titled Meal Substitutions and Modifications for definitions of "disability" and "major life activities." 1. If participant has a disability, describe the disability: 2. What are the "major life activities" affected by the disability? 3. Describe how the disability restricts the participanYs diet: +�. —� e.g., Celiac Disease)