Waller Independent School District

Student Diet Modification/Allergy Form

Student Last Name:______________________________First:_____________________________Date of Birth:_____________

School:___________________________________________________Grade:________________ Student ID:_______________

Parent/Guardian Contact Information

Name:__________________________________________________________________________________________________

Phone Number:_________________________________ Email:___________________________________________________

I give Health Services/School Nutrition Services permission to speak with the Physician to discuss the dietary needs described below.

__________________________________________________________________________ Date:________________________

Parent/Guardian Signature

Which meals will the student eat from the school cafeteria (please circle)?

BREAKFAST        LUNCH      NONE (If student does not eat from cafeteria, it is not necessary to complete this form).

The following must be completed by a licensed physician:

Does the student have a disability or life threatening food allergy requiring diet modification? Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990, a person with “a disability is any person who has a physical or mental impairment that substantially limits one or more life activity” including a life threatening food allergy.

Yes No *If the student does NOT have a disability and/or life threatening anaphylactic food allergy, this form does not need to be completed

                                         and will be disregarded.

Does the student have a prescription for an Epi-pen for a food allergy?

Yes No

Medical Diagnosis:_______________________________________________________________________________________

Major life activities affected by the disability:________________________________________________________________

Food to be Omitted:

____ Peanuts/Tree Nuts            ____ Fish/Shellfish                     ____Wheat*

____ Fluid Milk                          ____ All Dairy Products            ____ All foods containing milk as an ingredient*(Ex. Breaded items dipped in Milk)

____ Eggs by themselves           ____ All foods containing egg as an ingredient*(Ex. Baked goods)

____ Soy as a main ingredient (Ex. Soy milk, edamame, soy sauce)           ____ All foods containing soy as a major ingredient*(Ex. Soy in Processed foods)

____ Other:______________________________________

*If student must omit milk or egg as an ingredient, soy as a minor ingredient, wheat, or has multiple food allergies, we may suggest a meal is brought from home or special modifications will be made to accommodate them to receive meals in the cafeteria.

Accommodations Needed:

____ Nut free foods

____ Seafood free foods

____ No Milk/Dairy

____ Texture Modified – Only for student with a medical diagnosis of dysphagia

                ____ Pureed

                ____ Mechanical Soft Chopped

                ____ Mechanical Soft Ground

                ____ Other: _______________

Name of Licensed Physician (Print):__________________________________________________________________________

Physician’s Signature:___________________________________________________________Date:_____________________

Address:______________________________________________________________________Phone:____________________

PLEASE RETURN TO SCHOOL NURSE

Questions? EMAIL: mwarzon@wallerisd.net   OFFICE: (936)931-2347   FAX: (936)310-6584