Vermont's Agency of Education provides this two-page template for school and child nutrition programs when a child needs a meal modification that alters the USDA meal pattern. It first asks whether the child's IEP or 504 plan already contains the required information; if so, the form stops there. Otherwise the clinician lists foods to omit, how exposure affects the child, substitutions and needs such as texture, utensils or tube feeding.
A state-licensed health care professional completes the modification section and signs with a printed name; registered dietitians may also submit statements in school meals since July 1, 2025 and in CACFP since October 1, 2025. The parent or guardian's contact details go at the top.
Download the current version from the source each time; forms change without notice.
Vermont Medical Statement Form
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Yes. The form notes that registered dietitians may submit medical statements in the School Meals Programs as of July 1, 2025, and in the Child and Adult Care Food Program as of October 1, 2025. Otherwise it is signed by a state-licensed healthcare professional.
Not if the IEP or 504 plan already contains the required information. The template's first question asks exactly that, and if the answer is yes, the form says to stop. If the plan lacks those details, complete the rest of the form.
List the foods to avoid or omit, briefly explain how exposure affects the child, and give recommended substitutions. Then note any modified texture, special utensil, tube feeding, tracking assistance or other accommodations, and sign with your printed name.