1 To the Parent/Guardian of food allergies or special diets, it is neccessary to complete the If your child has any attached form. Modifications, avoidances, substitutions to any foods consumed in or school can only be made if the attached Food Allergy Evaluation Form is completed and signed by your medical professional’s office and returned to the Clinic or the Child Nutrition Department. This information is shared by Child Nutrition, the clinic, and the classroom. Moreover, our cafeteria has a system in place so that when a child with an allergy or dietary modification enters his/her ID number, an alert will flash on the computer screen, making the staff member aware of the child’s individual need. Please note this alert will not be put in place unless we have this form on file. Please remember that both the parent’s and the medical professional’s signature are required for any modifications, avoidances, or substitutions. Once the form is completed it is not necessary to have it done again yearly unless there are changes. Thank you.
2 LAKOTA LOCAL SCHOOL DISTRICT FOOD ALLERGY EVALUATION FORM PART A If your child has a food allergy or any special dietary needs, please completely fill out the information below. This form must be signed by a medical professional and returned to the clinic or child nutrition as soon as possible. STUDENT NAME: STUDENT ID#: SCHOOL: GRADE: CELL PHONE: PARENT/GUARDIAN: HOME PHONE: PARENT/GUARDIAN EMAIL ADDRESS: PHYSICIAN PHONE: PHYSICIAN: Does the child have a disability? YES / NO If YES, describe the major life activities affected by the disability. YES / NO Does the child have special nutritional or feeding needs? If YES, complete Part B of this form and have it signed by a licensed physician If the child does not have a disability, does the child have special dietary needs? YES / NO If YES, complete Part B of this form and have it signed by a recognized medical authority. PART B Please check mark any food allergies or intolerances your child has and list the foods that are to be omitted and substituted. MILK ALLERGY Milk and uncooked dairy products only (Ex. Fluid milk, yogurt, cheese, etc.) Milk, dairy, and ALL milk products (this includes cooked and denatured milk products. Ex. Breads, cookies, etc.) Fluid milk only Lactose Intolerant Foods to be omitted: Substitutions: * please make notation if it is a SEVERE/LIFE-THREATENING allergy * beverage substitutions may be limited due to regulations EGG ALLERGY Eggs only (Ex. Boiled, scrambled, individualized eggs) Eggs and ALL egg products (This includes cooked and denatured egg products. Ex. Breads, muffins, etc.) Foods to be omitted: Substitutions: NUT ALLERGY Other ____________________________________________ Peanuts Treenuts Foods to be omitted: Substitutions: SOY ALLERGY Soy only (Ex. Soy milk, soy yogurt, etc.) Soy and ALL soy products (This includes cooked and denatured soy products. Ex. Taco meat, chicken tenders, burger patty, etc.) Foods to be omitted: Substitutions: Revised 2-1-17 Page 1 of 2
3 LAKOTA LOCAL SCHOOL DISTRICT FOOD ALLERGY EVALUATION FORM OTHER ALLERGIES Allergies: Foods to be omitted: Substitutions: ADDITIONAL DIETARY RESTRICTIONS OR SPECIAL DIET Please describe: RELIGIOUS RESTRICTIONS (Does not need to be completed by a physician or medical authority) Please list foods restricted: What was the date of the first reaction, the symptoms, and the treatment? How responsible is your child in avoiding food items? Does your child wear a medical alert? YES / NO Is it necessary to avoid: physical contact, inhalation of, or ingestion of foods allergic to? Circle all that apply. *ALLERGY TABLE* Would you like your child to sit at an allergy table (applies to grades K-6 only)? YES / NO If YES, your child WILL be required to sit at an allergy table at your child's school until a written document is received from parent/guardian stating otherwise. Please have your physician complete a School Medication Permit if it is necessary for us to have medication at school. Forms can be found online or at school. If more than one medication is needed, a separate form is required for each medication. Medication must be delivered to the clinic by an adult in the original container. Children cannot carry medication to school unless it is an inhaler or Epi-Pen AND the doctor's order specifies it. Date: Parent/Guardian Signature: Date: Physician or Medical Authority Signature: ** Form can NOT be processed unless it is signed by a Physician or Medical Authority ** - OFFICE USE ONLY - Nurse Signature: Child Nutrition Signature: Date: Date: Page 2 of 2
4 LAKOTA LOCAL SCHOOL DISTRICT FOOD ALLERGY EVALUATION FORM - Non Discrimination Statement The U. S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities). If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html , or at any USDA office, or call (866) 632 - 9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U. S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250 - 9410, by fax at (202) 690 - 7442 or email at [email protected] . Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877 - 8339; or (800) 845 - 6136 (Spanish). USDA is an equal opportunity provider and employer.
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