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.