WebMEDICAL STATEMENT TO REQUEST. SPECIAL MEALS AND/OR ACCOMMODATIONS . 1. School or Agency 2. Site Name 3.Site Phone Number 4.Name of Child or Participant . 5.Age or Date of Birth. 6.Name of Parent or Guardian . 7.Phone Number. 8.Description of Child or Participant’s Physical or Mental Impairment Affected: 9.Explanation of D. iet Prescription ... WebA parent/guardian requesting special dietary accommodations for a student with a disability that restricts the diet must provide the Medical Statement for Special Dietary Needs signed by a state authorized medical authority. The request must contain the following information:

Nutrition Services / Special Dietary Accommodations

WebREQUEST FOR SPECIAL DIETARY NEEDS ACCOMMODATIONS INSTRUCTIONS 1. School/Agen cy Name: Print the name of the school or agen that is providing the form to … WebIf you have submitted a special dietary accommodation request in the past, please contact Nutrition Services. A Request for Special Dietary Accommodations form must be completed in its entirety and signed by your student’s physician (or a licensed health care professional authorized to write medical prescriptions in Washington State). lwt – food science and technology

Sample Letter from Health Care Professional Supporting Request …

WebSample Letter from Health Care Professional Supporting Request for Accommodations You may provide this sample letter to your health care professional to help him or her document ... [diet and exercise/oral medication/insulin through self-administration of injections multiple times a day via an insulin pen/insulin syringe/insulin pump] to manage ... Web11. Diet prescription and/or accommodation: Describe a specific diet or accommodation that has been prescribed by a physician or describe diet modification requested for a non-disabling condition. For example: "All foods must be either in liquid or pureed form. Participant cannot consume any solid foods." 12. WebA Request for Special Dietary Accommodations form must be completed in its entirety and signed by your student’s physician (or a licensed health care professional authorized to write medical prescriptions in Washington State). All special diet requests must be processed and approved by the Food Service director. kingson lighting netherlands