*Physician's signature is required for participants with a disability. For participants without a disability, a licensed physician, physician's assistant, or nurse practitioner must sign the form. Parent/legal guardian signature is acceptable for fluid milk substitution for a child with special medical or dietary needs other than a disability. The information on this form must be updated whenever necessary to reflect the current medical and/or nutritional needs of the participant.

This institution is an equal opportunity provider.

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 affects 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. Foods to Be Omitted: List specific foods that must be omitted. For example, "exclude fluid milk." Suggested Substitutions: List specific foods to include in the diet. For example, "calcium fortified juice."
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 (ADAAA) of 2008 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 an d the ADAAA.) Information regarding the ADAAA, which expanded the definition of disability, can be found at:
http://www.law.georgetown.edu/archiveada/documents/ComparisonofADAandADAAA.pd