Oregon child nutrition sponsors, including schools, child care centers and summer meal sites, use this statement when a participant needs a meal accommodation because of a disability. The signer describes the major life activity or bodily function the impairment affects, lists foods to omit or avoid, and gives substitutions. The sponsor then records the accommodations it will make and signs Part III.
A state-licensed health care professional authorized to prescribe, or a registered dietitian for school meals and CACFP, completes and signs Part II. The parent, guardian, adult participant or organization completes Part I, and the sponsoring organization completes Part III.
Download the current version from the source each time; forms change without notice.
Medical Statement to Request Special Meals and/or Accommodations
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Yes, for school meals and the Child and Adult Care Food Program. The form cites 7 CFR 210.10(m) and 7 CFR 226.20(g)(1), which authorize registered dietitians to complete and sign medical statements for those programs. Otherwise Part II needs a state-licensed health care professional authorized to write prescriptions.
Yes. Oregon uses one statement across school meals, the Child and Adult Care Food Program and the Summer Food Service Program, and its instructions give examples such as a school or a child care center. The sponsoring organization enters its name and the site where meals are served.
Part II asks three things: the major life activity or bodily function affected by the physical or mental impairment that restricts the diet, the foods to omit or avoid, and the foods to substitute with recommended alternatives. Then print your name, sign and date it.