SPECIAL DIET STATEMENT

Patrons: If your child requires a special diet due to religious or health reason, please have this form completed by a medical personnel or cleric, whichever is appropriate. The foods which are unacceptable and their substitutes must be listed on this form. Upon its completion this form is to be returned to the child care center or provider’s home where your child is enrolled. Within its food-menu capabilities, government certified child care programs will make every effort to comply with your child’s dietary needs. In the event that it is not within food-menu capability to meet your child’s dietary needs, accommodations will be made on a case by case basis.

Child’s Name __________________________________________________________

Parent/Guardian Name __________________________________________________

Center or Provider Home where your child is enrolled __________________________

____________________________________________________________________

Unacceptable Foods

Substitute Foods

Physician or Cleric’s Name _______________________________________________

Physician or Cleric’s Address _____________________________________________

____________________________________________________________________

Signature of Physician or Cleric

Date