Dietary Modification Medical Statement Form

May 2024

Food Allergies

The School Nutrition Program can make reasonable accommodations for children who are unable to eat school meals because of disabilities that restricts their diet. School cafeterias will provide modifications 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, or nurse practitioner. In order to ensure the provision of appropriate and safe meals, the healthcare professional must complete a 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 and will provide the date at which the cafeteria can begin the child’s special diet. Planning for meal modifications and training staff requires time; therefore, there may be a few days until the cafeteria has the special menu in place for the student. Until the special meal has been developed, foods provided by the parent or guardian would be the safest option.

 In order to continue a modified menu from one school year into the next, parents or guardians should 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.


If you have questions, please contact the School Nutrition Program at 434-432-2761