Nutrition Interventions for Children with Special Health Care Needs

Appendix P
Diet Prescription for Meals at School
Section 504 of the Rehabilitation Act of 1973 assures handicapped students access to school
meal service, even if special meals are needed because of their handicap. If special meals are
needed and requested, certification from a medical doctor must:
1. Verify that special meals are needed because of a disability or medical condition
2. Prescribe the modified diet and/or textures allowed
Name of student for whom special meals at school are requested:
Disability or medical condition that requres the student to have a special diet:
Foods Prescribed:
Texture Consistency Required:
Feeding Positioning and Assistance:
Other Information Regarding Diet or Feeding (Please provide additional information on the
back of this form or attach to this form.)
I certify that the above named student requires special school meals prepared as described
above because of the student’s disability or chronic medical condition.
Physician/Recognized Medical Authority Signature Office Phone Number Date
376 Nutrition Interventions for Children With Special Health Care Needs