Waller Independent School District
Student Diet Modification/Allergy Form
Student Last Name:______________________________First:_____________________________Date of Birth:_____________
School:___________________________________________________Grade:________________ Student ID:_______________
Parent/Guardian Contact Information
Phone Number:_________________________________ Email:___________________________________________________
I give Health Services/School Nutrition Services permission to speak with the Physician to discuss the dietary needs described below.
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?
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)
*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.
____ Nut free foods
____ Seafood free foods
____ No Milk/Dairy
____ Texture Modified – Only for student with a medical diagnosis of dysphagia
____ Mechanical Soft Chopped
____ Mechanical Soft Ground
____ Other: _______________
Name of Licensed Physician (Print):__________________________________________________________________________
PLEASE RETURN TO SCHOOL NURSE
Questions? EMAIL: email@example.com OFFICE: (936)931-2347 FAX: (936)310-6584