Health Services Department – Bremerton School District 100-C

134 Marion Avenue North

Bremerton, WA 98312-3542

Office: 360.473.1073 Fax: 360.473.1043


Diet Prescription for Meals at School
This document is in effect for the current school year and must be renewed annually.
Please fax completed form to 360.473.1043
School: ______Year: ______

This section must be completed by the PARENT / GUARDIAN: (Please Print)

Student: DOB: Grade: Age: M or F
Parent/Guardian: Parent/Guardian E-mail:
Home Address:
Home Phone:
Work Phone: Cell Phone:
Signature: Date:
Health Care Provider: Phone:
□ I give my permission for exchange of information between the School Nurse and the Health Care Provider.
Please answer the following:
  1. Does your child have a disability? □ Yes □ No If Yes, describe the major live activities affected by the disability:
  1. If your child is NOT disabled, does he/she have special Nutritional or Feeding needs? □ Yes □ No If Yes, please describe: ______
  2. Does your child have an EpiPen®, EpiPen Jr®or other epinephrine injection device for specific food(s)? □ Yes □ No

The following is to be completed by the Health Care Provider/Authorized Medical Authority: (MD, DO, ND, DMD, DC, PA, ARNP or CNM)

Medical Condition: ______

Diet Prescription: ______

(Mark all that apply):

Food Intolerance(s): / Eliminate ALL foods that contain any form of:
□ Eggs – PURE FORM ONLY / □ Egg Proteins / □ Other:
□ Milk – PURE FORM ONLY* / □ Milk Proteins
□ Milk and Dairy – ONLY* / □ Fish
□ Soy – PURE FORM ONLY / □ Shellfish
□ Wheat (due to Celiac Disease) / □ Peanuts
□ Red Dye / □ Soy

*Please note if Juice or Water may be offered in place of Milk: □ Yes □ No

** Is Milk eliminated due to a Milk allergy? □ Yes □ No Or is Milk eliminated due to Lactose Intolerance? □ Yes □ No

***Diabetic Diets “Carbohydrate Distribution/Counting”= Breakfast______Lunch______Snack______(# of Carbohydrates per meal)

Any other Specific Dietary Need(s): ______

Specific Foods to OmitSpecific Foods to Substitute




I certify that the above named student requires special dietary accommodations in accordance with the instructions indicated, as there exists a medicalcondition which makes administration advisable during school hours.
Health Care Provider/Authorized Medical Authority signature: Date:
Print or Stamp Name

Updated: 07/07/15

Meal Substitutions for

Medical or Special Dietary Reasons

Child Nutrition Program regulations require schools, institutions and sponsors to offer lunches, breakfasts, suppers and snacks which meet the meal patterns identified in the program regulations. This instruction sets forth the policy for food substitutions for medical or special dietary needs of handicapped and non-handicapped children.


A handicapped child, as defined in 7 CFR Part 15b. Is one who has a physical or mental impairment which substantially limits one or more major life activities. Major life activities are defined to include functions such as caring for themselves, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working. Schools, institutions and sponsors are required to make substitutions in foods listed in the meal patterns for those handicapped children who are unable to consume specified food items.

Food service personnel are not to make the determinations of whether a child is handicapped as defined above. Rather, food service personnel shall accept either: the certification of the official of the school, institution or sponsor who classifies students as handicapped; or the certification of a physician that an individual student is handicapped, as defined above.

On a case-by-case basis, a handicapped child shall be provided substitutions in foods only when supported by a statement signed by a physician licensed by the State. The supporting statement shall identify:

A The individual’s handicapping condition and an indication that the handicap restricts

the child’s diet;

B The major life activity affected by the handicapping condition; and

C The food or foods to be omitted from the child’s diet and the food or choice of foods that

may be substituted.

The State agency should make the pertinent section of 7 CFR Part 15b available to schools, institutions and sponsors, as appropriate. The school, institution or sponsor should provide parents or guardians with the pertinent section of 7 CFR Part 15b upon request so that their physician may correctly assess whether an individual child’s handicap meets the regulatory criteria. Generally, children with food allergies or intolerance are not handicapped as defined in this section. However, it is possible that such food allergies or intolerance will limit a major life activity. When faced with a request for special meals for such children, the food service personnel must abide by the determination of the physician or, if appropriate, the official who classifies the child as handicapped.