Perpich Arts High School Dietary /Modification Restriction Form Student Name: Date of Birth: Grade: 11 / 12 Please list any dietary restrictions or special diets: What is the medical diagnosis? List any allergies or food intolerances: __________________________________________________________________________________ List specific foods that can substitute for foods not allowed: Has student received a nutrition consultation? Yes No Date_______________ I authorize the School District to provide special meals as described above. *Physician’s Signature: Phone Date Phone Date or CNP/PA Signature: Clinic Name/Address: Fax #: Parent/Guardian’s Signature: Phone Date * NOTE: A physician’s signature is required in order to make mandated dietary modifications and/or food substitutions due to a student’s disability. If a student does not have a disability but has a medical condition requiring dietary modifications/substitutions, a Physician, CNP or PA may sign the form, and the Food Services will make a reasonable attempt to accommodate the request but is not mandated to do so without a disability status. Parent/guardian may sign the form without health provider signature if there are dietary preferences unrelated to a health condition or disability. These preferences will be taken into consideration, but Food Service is not required to make dietary modifications. Or Send to: Perpich Center for Arts Education, High School 6125 Olson Memorial Highway Golden Valley, MN Attention: School Nurse Please contact: Wendy Sandstrom, RN, Licensed School Nurse at 763-279-4193 for assistance. Copies to: ____ Pupil Health Record ____ Lunch Room Staff ____ Food Service Director
Perpich Arts High School Dietary /Modification Restriction Form Student Name: Date of Birth: Grade: 11 / 12 Please list any dietary restrictions or special diets: What is the medical diagnosis? List any allergies or food intolerances: __________________________________________________________________________________ List specific foods that can substitute for foods not allowed: Has student received a nutrition consultation? Yes No Date_______________ I authorize the School District to provide special meals as described above. *Physician’s Signature: Phone Date or CNP/PA Signature: Phone Date Clinic Name/Address: Fax #: Parent/Guardian’s Signature: Phone Date * NOTE: A physician’s signature is required in order to make mandated dietary modifications and/or food substitutions due to a student’s disability. If a student does not have a disability but has a medical condition requiring dietary modifications/substitutions, a Physician, CNP or PA may sign the form, and the Food Services will make a reasonable attempt to accommodate the request but is not mandated to do so without a disability status. Parent/guardian may sign the form without health provider signature if there are dietary preferences unrelated to a health condition or disability. These preferences will be taken into consideration, but Food Service is not required to make dietary modifications. Or Send to: Perpich Center for Arts Education, High School 6125 Olson Memorial Highway Golden Valley, MN Attention: School Nurse Please contact: Wendy Sandstrom, RN, Licensed School Nurse at 763-279-4193 for assistance. Copies to: ____ Pupil Health Record ____ Lunch Room Staff ____ Food Service Director
Special_Nutr_Needs_Form_2014-2015.docx