Special Dietary Needs and Allergies

Special Dietary Needs Medical Statement Form–English

Special Dietary Needs Medical Statement Form–Espanol

Wayne Township adheres to specific USDA guidelines in providing special diet accommodations for students. In accordance with the criteria set forth in 7 CFR Part 15b, those students who are unable to eat the school meal due to a disability/medical need/or impairment are accommodated, at no additional charge. Dietary needs due to lifestyle and religious reasons are important to our school but not a requirement by USDA to make accommodations. Our school will try to accommodate lifestyle and religious needs through our current menu choices. Please review the following information if your child requires special diet consideration.

Process for Requesting Accommodations for Special Dietary Needs

The steps in the process to request special accommodations are

1. for the parent(s)/caregiver(s) to complete the Special Dietary Needs Medical Statement Form English or Espanol and immediately return to the school nurse or the district staff dietitian (insert link to Special Dietary Needs Medical Statement form
2. the request will be reviewed and processed
3. the form may be returned to parent/guardian for additional medical signatures. For example, if the substitutions needed for accommodations fall outside of the USDA meal pattern, the Medical Statement form must be signed by an authorized medical authority with prescriptive privileges in the state of Indiana
4. accommodations will be adjusted accordingly based on review

Special Dietary Needs and Allergies Contact

The safety of your child comes first. If you have a child with a disability/medical need or impairment that affects their diet, please submit your request for accommodation by completing this form and submitting to Amanda Lyons, the district Staff Dietitian, at the Child Nutrition Office (1155 S High School Road) or by email (amanda.lyons@wayne.k12.in.us).

For more information about accommodations to school meals and the meal service for students with disabilities in Wayne Township, please contact Amanda Lyons, RD at 317-988-7955.

USDA Nondiscrimination Statement

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. 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 Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

How to Discontinue Special Dietary Accommodations

If you wish to discontinue your child’s special dietary accommodation or your child no longer requires a special dietary accommodation, please fill out the form below and return to Amanda Lyons, RD at 1155 S High School Rd or email to amanda.lyons@wayne.k12.in.us.

Discontinuation of Special Dietary Accommodations Form

This institution is an equal opportunity provider.