North Dakota schools use this statement, part of the 2025-26 free and reduced meal packet, when a child's physical or mental impairment requires a school meal modification. The provider explains how the impairment restricts the diet and how exposure affects the child, sets the texture, lists foods to omit with substitutions, and notes adaptive equipment. The diagnosis itself doesn't have to be shared.
The school fills in its details and the parent provides the child's name, age and contact. A licensed physician, physician assistant, nurse practitioner (ARNP) or registered dietitian completes item 12 and signs with office name, address and phone.
Download the current version from the source each time; forms change without notice.
Medical Statement to Request School Meal Modification
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
No. The instructions state that the diagnosis is not required to be shared. Item 8 instead asks how the physical or mental impairment restricts the child's diet and how exposure to the food or beverage affects the child, as prescribed by the healthcare professional.
Until the licensed healthcare professional requests that it be changed or stopped. The form should be updated as needed to reflect the participant's current medical or nutritional needs, but it does not expire on a fixed schedule.