Dietary Modification Medical Statement Form
July 2025
Food Allergies
School cafeterias can make reasonable meal accommodations for students who are unable to eat school meals because of disabilities that restricts their diets. Meal modifications will be provided for students on a case-by-case basis when requests are accompanied by a written statement from a licensed healthcare professional, such as a licensed physician, physician’s assistant, nurse practitioner or registered dietitian. In order to ensure the provision of appropriate and safe meals, the healthcare professional must submit this information using the school division’s Dietary Modification Medical Statement Form. This required medical form is available on-line under the School Nutrition Department tab. Paper copies are also available at each school. Once completed, the Medical Statement Form must be returned to either the school nurse or faxed directly to the Supervisor of School Nutrition at 434-432-9560. Upon receipt of the form, the Supervisor of School Nutrition will then contact the parent/guardian to discuss the options available for accommodating the child’s need.
In order to continue a modified menu from one school year into the next, parents must notify the Supervisor of School Nutrition at the beginning of each school year to request the continuation of services.
Other dietary requests, including those related to general health concerns, personal preferences, and moral or religious reasons are not disabilities and are optional for schools to accommodate. Most of these needs can be met within the general meal plan since a variety of choices are offered to students daily.
For more information about requesting special meal modifications for students with disabilities, please contact the Supervisor of School Nutrition, Kara Scott at 434-432-2761 ext. 5045 or through email at [email protected]