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Diet Prescription For School Meals

Diet Prescription for School Meals

 

 

School: __________________________________   School Year: _________________

 

Name of student for whom special meals at school are requested:

_________________________________________(D.O.B.)_______________________

 

Grade: _____________           Homeroom Teacher: ___________________________

 

Disability or medical condition that requires the student to have a special diet. Include a brief description of the major life activity affected by the student’s disability: ________________________________________________________________________

Diet Prescription:   (Check all that apply.)

 ____ Diabetic                   _____ Reduced Calorie                 ____ Increased Calorie

____ Modified Texture     ____ Other (Describe) ________________________

 

Foods Omitted & Substitutions: (Please check food groups to be omitted. List specific foods to be omitted and suggest substitutions using the back of this form or information attachment.)

____ Meat & Meat Alternates   ____ Milk & Milk Products   _____ Other (Describe):

____ Bread & Cereal Products     ____ Fruits & Vegetables

 

Textures Allowed: (Check the allowed texture.)

____ Regular     ____ Chopped     ____ Ground     ____ Pureed

 

Other Information Regarding Diet or Feeding: (Please provide additional information on the back of this form or attach to this form.)

 

Please avoid the following:

___ Pre-breaded items because of their higher calorie value.

___ Casserole Type entrees or vegetables

___ Fried foods

___ Added gravies or sauces or provide fat free alternatives

___ See attached for additional information

 

Alternatives suggested:

___ Baked, broiled, steamed, boiled vegetables and meat entrees

___ Raw vegetables, salads with low fat/fat free dressings

___ Fruit—fresh or canned lite or with no syrup

 

I certify that the above named student needs special school meals prepared as described above because of the student’s disability or chronic medical condition

 

                                                                                        __________   ______________

(Physician/Recognized Medical Authority Signature)                 (Office phone number)                           (Date)

 

___________________________________________     _____________________________     ___________________

               (Parental/Guardian Signature)                                     (Phone number/s)                                 (Date)

 

 

 






Hale County Board of Education | 1115 Powers Street | Greensboro, AL 36744 | Ph: 334.624.8836