SPECIAL D=
IET
STATEMENT
P=
atrons: If your child requires a special di=
et due
to religious or health reason, please have this form completed by a medical
personnel or cleric, whichever is appropriate. The foods which are unaccept=
able
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 wh=
ere
your child is enrolled. Within its food-menu capabilities, government certi=
fied
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 m=
eet
your child’s dietary needs, accommodations will be made on a case by =
case
basis.
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Child’s Name
__________________________________________________________
Parent/Guardian Name
__________________________________________________
Center or Provider Home wher=
e your
child is enrolled __________________________
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_=
___________________________________________________________________
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Unacceptable
Foods |
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Substitute
Foods |
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Physician or Cleric’s =
Name
_______________________________________________
Physician or Cleric’s
Address _____________________________________________
J,.///////////i/./.
____________________________=
________________________________________
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Signature of Physician or =
Cleric |
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Date |
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