Special Diet Form

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Accommodating Children with Special Dietary Needs

The School Nutrition Program accommodates children with special dietary needs if a Medical Statement form is submitted. The Medical Statement form must be completed and signed by a licensed Physician or Medical Authority.

If the child’s diet changes during the school year a new Medical Statement must be submitted.

The original Medical Statement is kept on file in the School Nutrition Department. A copy of the statement is kept on file with the School Cafeteria Manager and the School Nurse. Menu changes are made through the School Nutrition Department and are communicated to the School Cafeteria Manager and School Nurse (if requested).

Download the Medical Statement English or pick up a copy at the school.

Please contact the School Nutrition Department for assistance: 

828.255.5932 phone
828.255.5899 fax

Medical Statement for Students with Special Nutritional Needs for School Meals

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.

Medical Statement (English)58 KB (Updated: April 30, 2014)
Medical Statement (Spanish) 89 KB (Updated: March 3, 2017)
Fluid Milk Substitution Form 100 KB (Updated: March 10, 2021)

This institution is an equal opportunity provider.