Section 504 of the Rehabilitation Act of 1973 assures handicapped students access to school meal service, even if special meals are needed because of their handicap.

“Handicapped student” means any student who has physical or mental impairment which substantially limits one or more major life acivities, has a record of such an impairment, or is regraded as having such as impairment.

If special meals are needed and requested, certification from a medical doctor must (1) verify that special meals are needed because of the handicap, and (2) prescribe the alternate foods and forms needed.

Completion of the following by a students doctor/dietitian will provide the necessary certification:

Name of student for whom special meals are requested: ___________________________

Meal Plan Prescribed: _______________________________________________________

Form allowed (e.g., fresh, baked, ground, blended, etc.): ___________________________

Meat and Meat Alternates:
Milk and Milk Products:
Bread and Cereal:
Fruits and Vegetables:

Other Dietary Information and Directions:



I certify that the above named student is in need of special school meals prepared from the above indicated foods and forms because of a handicap.

____________________________________________________ _____________
Physician/Dietitian Signature Date