Please read the instructions, complete and print the request form at the bottom of this page.

Instructions:

LYNN PUBLIC SCHOOLS MEDICAL STATEMENT TO REQUEST SPECIAL MEALS AND/OR ACCOMMODATIONS CHILD NUTRITION PROGRAMS INSTRUCTIONS

Note: According to 7 CFR, part 226.20 and FNS Instruction 783-2, Rev.1, food substitutions for medical reasons can be made only when there is a written statement.

1. School/Agency: Print the name of the school or agency that is providing the form to the parent.

2. Site: Print the name of the site where meals will be served (e.g., school site, child care center, community center, etc.)

3. Site Telephone Number: Print the telephone number of site where meal will be served. See #2.

4. Name of Participant: Print the name of the child or adult participant to whom the information pertains.

5. Age of Participant: Print the age of the participant. For infants, please use Date of Birth.

6. Name of Parent or Guardian: Print the name of the person requesting the participant's medical statement.

7. Telephone Number: Print the telephone number of parent or guardian.

8. Check One: Check a box to indicate whether participant has a disability or does not have a disability.

9. Disability or Medical Condition Requiring a Special Meal or Accommodation: Describe the medical condition that requires a special meal or accommodation (e.g., juvenile diabetes, allergy to peanuts, etc.)

10. If Participant has a Disability, Provide a Brief Description of Participant's Major Life Activity Affected by the Disability: Describe how physical or medical condition is affected by the disability. For example: "Allergy to peanuts causes a life-threatening reaction."

11. 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. Indicate Texture: Check a box to indicate the type of texture of food that is required. If the participant does not need any modification, check "Regular".

13. A. Foods to Be Omitted: List specific foods that must be omitted. For example, "exclude peanut butter."
    B. Suggested Substitutions: List specific foods to include in the diet. For example, "sunflower seed spread."

14. Adaptive Equipment: Describe specific equipment required to assist the participant with dining. (Examples may include a sippy cup, a large handled spoon, wheel-chair accessible furniture, etc.)

15. Signature of Preparer: Signature of person completing form.

16. Printed Name: Print name of person completing form.

17. Telephone Number: Telephone number of person completing form.

18. Date: Date preparer signed form.

19. Signature of Medical Authority: Signature of medical authority requesting the special meal or accommodation.

20. Printed Name: Print name of medical authority.

21. Telephone Number: Telephone number of medical authority.

22. Date: Date medical authority signed form.The American with Disabilities Act Amendment Act defines a "disability," in part, as a physical or mental impairment that substantially limits a major life activity or major bodily function of an individual.

(For additional information on the definition of disability, please refer to Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act Amendments Act of 2008) Information regarding the ADAAA, which expanded the definition of disability,