Illinois schools, child care centers and summer meal sites can use this ISBE sample form to request a meal modification for a child whose physical or mental impairment restricts the diet. The medical authority describes the impairment, lists foods or ingredients to avoid with alternatives, and adds any other services needed. It covers school nutrition programs, CACFP and SFSP.
A state licensed healthcare professional authorized to prescribe under Illinois law, or a registered dietitian, completes section 2 and signs. The parent or guardian completes the child details and signs section 3.
Download the current version from the source each time; forms change without notice.
Medical Authority Modified Meal Request Form
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ISBE lists three elements: enough information about the child's impairment for the operator to understand how it restricts the diet, an explanation of what must be done to accommodate it, and, if applicable, the foods to omit and recommended alternatives. Section 2 of the sample form asks for exactly those.
Yes. ISBE posts a Spanish version of the Medical Authority Modified Meal Request Form, and of the parent's Preference Modified Meal Request Form, on its School Nutrition Special Dietary Needs page, which serves both school and CACFP operators.