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Special Diet Form

Accommodating Children with Special Dietary Needs

The School Nutrition Program accommodates children with special dietary needs if a Medical Statement form is submitted. The Medical Statement form must be completed and signed by a licensed Physician or Medical Authority. A new Medical Statement must be submitted each school year to the School Cafeteria Manager or mailed to the School Nutrition Department. If the child’s diet changes during the school year a new Medical Statement must be submitted.

The original Medical Statement is kept on file in the School Nutrition Department. A copy of the statement is kept on file with the School Cafeteria Manager. Menu changes are made through the School Nutrition Department and are communicated to the School Cafeteria Manager (if requested).

Download the Medical Statement or pick up a copy at the school.

Please contact the School Nutrition Department for assistance:

Phone: (252) 598-1038
Fax: (252) 598-1037

Medical Statement for Students with Special Nutritional Needs for School Meals

When completed fully, this form gives schools the information required by the U.S. Department of Agriculture (USDA), U.S. Office for Civil Rights (OCR), and U.S. Office of Special Education and Rehabilitative Services (OSERS) for meal modifications at school. See “Guidance for Completing Medical Statement for Students with Special Nutritional Needs for School Meals” for help in completing this form.


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