Special Diet Statement

Students with food allergies or sensitivities must be accommodated if we receive appropriate documentation.  The attached form is a standard document supported by Michigan Department of Education's Nutrition Services division.  Families requesting accommodation must complete this document AND have it signed by a Physician verifying the information.  This is required.  If no document is on file, we are not permitted to offer meal pattern changes to individual students.  Should you have any questions, please reach out to the DPS Foodservice team at 269-646-5081 (ext. 5502) It is requested that any student with a food allergy make certain to connect with the cafeteria manager they will be working with and discuss their individual plan/needs.


Special Diet Statement  

Why am I being asked to fill out this form?   Institutions or organizations who sponsor and operate a federally funded Child Nutrition Program must make  reasonable substitutions to meals and/or snacks on a case-by-case basis for participants who are considered to have a disability that restricts their diet.* According to the ADA Amendments Act, most physical and mental impairments  that substantially limit or affect one or more major life activities or bodily functions will constitute a disability.  

Sponsors are not required to accommodate special dietary requests that are not a disability. This includes  requests related to religious or moral convictions or personal preference. If these requests are accommodated,  sponsors must ensure that all USDA meal pattern and nutrient requirements are met.  

This form must be completed by a licensed physician, physician assistant, or an advanced practice registered nurse, such  as a certified nurse practitioner. Updates to this form are required only when a participant’s needs change.  

Note to Districts/Schools: Parents/Guardians may provide a written request for lactose-free milk without a physician’s  signature. Lactose-free milk served must meet meal pattern requirements for the program.  

PDF DocumentSpecial Dietary Accommodation Form