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Medical Statement for Special Dietary Needs

Children with Disabilities and Special Dietary Restrictions


Click on this form to download and print a copy of the form to be completed by your physician. Please return the completed form to the School Nurse. 

If your child has any food allergy: Please call the school nurse for a food allergy form. This form needs to be filled out by your physician.

DPI requires that we have this note on file for our lunch meal program. We ask that you contact the school nurse and classroom teacher of any food allergy your son/daughter may have.