If you need assistance with this form, contact Esha Naaz, Rd, LD at 770-888-3473 ext. 310316 or email enaaz@forsyth.k12.ga.us.
The medical statement below must be completed and submitted to enaaz@forsyth.k12.ga.us before any meal substitutions can be made. If changes are needed, the parent/guardian is required to submit a new form.
Guidance
Disability
Under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act Amendments Act (ADAAA) of 2008, “a person with a disability” means any person who has a physical or mental impairment which substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such an impairment. According to the ADAAA, most physical and mental impairments constitute a disability.
Major life activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentration, thinking, communicating, and working. Major life activities also include the operation of a major bodily function, including but not limited to, functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions.
U.S. Department of Agriculture (USDA) regulations require reasonable modifications to school meals to accommodate children with disabilities when the disability restricts the child’s diet. Modifications will be determined on a case-by-case basis.
Accommodation for special dietary requests that can be made within the Program meal pattern requirements do not require a medical statement. The School Food Authority may require a medical statement signed by a State licensed healthcare professional be submitted to accommodate the request.
State Licensed Healthcare Professional is a professional who is authorized to write medical prescriptions under State law, and may include a physician, nurse practitioner, or a physician’s assistant. Pursuant to the Final Rule: Child Nutrition Programs – Meal Patterns Consistent With the 2020–2025 Dietary Guidelines for Americans, effective July 1, 2025, program operators are also required to accept written medical statements from Registered Dietitians as sufficient documentation for the purpose of providing special dietary accommodations.
Instructions
Part 1: To be completed by the parent/guardian for all special dietary requests.
Part 2: Please provide sufficient details for the school food service to make an appropriate accommodation. This section must be completed and signed by a State licensed healthcare professional when the modified meal does not meet the Program meal pattern requirements. The district Section 504 Coordinator, School Food Service Professional and/or other team members will work with you to manage the process of meal modifications.
Signature: Signature from a State licensed healthcare professional is required when the reasonable modification does not meet the meal pattern.
In accordance with federal civil rights law and USDA civil rights regulations and policies, the USDA, its agencies, offices, employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the state or local agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
- Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Mail Stop 9410, Washington, D.C. 20250-9410;
- Fax: (202) 690-7442; or
- Email: program.intake@usda.gov.
USDA is an equal opportunity provider, employer, and lender.