Special Dietary Needs Allergies & Diabetic Carb Counts
The Medical Statement for Students with Unique Mealtime Needs for School Meals helps schools provide meal modifications for students who require them. Schools cannot change food textures, make food substitutions, or alter a student’s diet at school without proper documentation from the healthcare providers. Completion of all items will allow your child’s school to create a plan with you for providing safe, appropriate meals and snacks to your child while at school. Your participation in this process is very important. The sooner you provide this signed and completed form to your child’s school, the sooner the School Nutrition Program and their staff can prepare the food your child needs. Your signature is required for your school to take action on the Medical Statement.
Follow these steps to get started:
1) Complete all sections of PART A of the Medical Statement available for download
2) Take the Medical Statement to your child’s pediatrician or family doctor/nurse practitioner/physician’s assistant and have him/her complete PART B.
3) Return the fully completed Medical Statement with signatures from both parent/guardian and medical authority, to your child’s teacher, principal, nurse, Special Education case manager, or Section 504 case manager, School Nutrition Administrator, or the school staff person who gave you the blank form.
4) Ask the school when a team, including you, the school system’s School Nutrition Administrator and others, will meet to consider the information provided on the form. You may also invite people from the community who are knowledgeable about your child’s feeding and nutrition issues to the meeting. These would be people who could help school staff design a school mealtime plan for your child, like your child’s pediatrician, nurse, speech-language pathologist, occupational therapist, registered dietitian or personal care aide.
Please contact School Nutrition Services at (336) 242-5635 for a holistic approach to your child's allergies. Download the Allergen Awareness Plan listed below for more information.
DCS Allergy Awareness Plan & Nutrient Details by Category
Food Allergies in Recipes
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: email@example.com.
This institution is an equal opportunity provider.