COLLEGE PLACE PUBLIC SCHOOLS 1755 S. College Avenue College Place, WA 99324

Health Services

509.525.4827 Fax 509.525.3741 Cpps.org

Menu Modification Request for Student with Disability in Child Nutrition Programs

PARENT/GUARDIAN MUST COMPLETE THIS SECTION Student Name:

________

Date of Birth:

School Attended:

_______ ________

Grade:

Parent/Guardian Name:

_________

Phone Number:

Mailing Address:

______

Age:

___

__________________

________________________

City/State/Zip:

Signature of Parent/Guardian

Date

DIET ORDER - PHYSICIAN MUST COMPLETE THIS SECTION (this form must be signed by a licensed physician).

List student’s disability (include life-threatening food allergies which cause an immune system response to a particular food/ingredient/additive): What is the major life activity affected:

Describe how the disability restricts student’s diet:

List all food(s) to be omitted:

List all food(s) to be substituted:

Describe any other comments about the student’s eating or feeding patterns.

Signature of Licensed Physician

Date

CPPS.ORG College Place Public School District is an equal opportunity employer and complies with all requirements of the ADA.

COLLEGE PLACE PUBLIC SCHOOLS 1755 S. College Avenue College Place, WA 99324

Health Services

509.525.4827 Fax 509.525.3741 Cpps.org

Petición para Modificación de Menú para Estudiante con Discapacidad En Programas de Nutrición para Niños

PADRE/GUARDIAN NECESITA COMPLETAR ESTA SECCION Nombre de Estudiante:

_________________

Escuela Asistiendo: Nombre de Padre/Guardián:

____

_

Fecha de Nacimiento:

_

Grado:

_________

Dirección:

_________________

Cuidad/Estado/Área Postal:

_

Firma de Padre/Guardián

Número de Teléfono:

__

Edad:

________________

Fecha

Orden de Dieta/ Para el Doctor-DIET ORDER – PHYSICIAN MUST COMPLETE THIS SECTION (this form must be signed by a licensed physician)

List student’s disability (include life threatening food allergies which cause en immune system response to a particular food/ingredient/additive): What is the student’s special dietary need:

What is the major life activity affected:

Describe how the disability restricts student’s diet:

List all food(s) to be omitted:

Describe any other comments about the student’s eating or feeding patterns.

Signature of Licensed Physician

Date

CPPS.ORG College Place Public School District is an equal opportunity employer and complies with all requirements of the ADA.