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State-licensed healthcare professionals authorized under Illinois law or registered dietitians complete required medical sections, including impairment description, foods to avoid, alternatives, and additional accommodations. 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Adult Care Food Program, & Summer Food Service Program  \nThis form may be used to request a meal modification for a child with a physical or mental impairment that restricts their diet. Portions ofthis form must be completed by a State Licensed Healthcare Professional (who is authorized to write medical prescriptions under Illinois law) or a Registered Dietitian.  \n\n| SECTION 1: CHILD INFORMATION |\n| --- |\n| Child’s Name:   Date of Birth:   Facility Name:   Grade:   |\n| SECTION 2: MEAL MODIFICATION INFORMATION\u003Cbr>TO BE COMPLETED BY A STATE LICENSED HEALTHCARE PROFESSIONAL OR REGISTERED DIETITIAN |\n| 1. Provide a description of the child’s physical or mental impairment and how it restricts their diet and/or access to meal programs.\u003Cbr>2. Are there any food items and/or ingredients that must be avoided? ☐ Yes ☐ No If yes, please list the food items and/or ingredients to be avoided.\u003Cbr>List alternatives that may be provided for any items or ingredients above.\u003Cbr>3. List any additional modifications and/or services needed to accommodate the child’s impairment or disability. |\n| SECTION 3: SIGNATURES |\n| Parent/Guardian Name:   Relationship:   Phone:   Email:   Parent/Guardian Signature:   Date:   Medical Authority Name (First & Last)  \u003Cbr>Medical Authority Signature   Date   |\n\n\n| SEND COMPLETED FORMS TO |  |  |\n| --- | --- | --- |\n| Name: Title:\u003Cbr>Facility: | Email:\u003Cbr>Fax: | Mailing Address: |\n| SPONSOR/SCHOOL FOOD AUTHORITY USE ONLY |  |  |\n| Date Received:   Received By:   Date(s) of Follow-Up Communication *  *Attach documentation of pertinent information received from any follow-up communication to this form. |  |  |\n\nNondiscrimination Statement  \nIn accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.  \nProgram information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.  \nTo file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form online, or obtain the form from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:  \n1. Mail:  \nU.S. Department of Agriculture  \nOffice of the Assistant Secretary for Civil Rights  \n1400 Independence Avenue, SW  \nWashington, D.C. 20250-9410; or  \n2. Fax:  \n(833) 256-1665 or (202) 690-7442; or  \n3. Email:  \n[program.intake@usda.gov](program.intake@usda.gov)","cbCaifTTeWxakrOu","https://ap.wps.com/l/cbCaifTTeWxakrOu","pdf",1360244,"English","# Section 1: Child Information\n# Section 2: Meal Modification Information\n## Signatures and Authorization\n# SEND COMPLETED FORMS TO\n# Sponsor/School Food Authority Use Only\n# Nondiscrimination Statement","[{\"question\":\"Who is allowed to complete the medical portion of the form?\",\"answer\":\"A state licensed healthcare professional authorized to write medical prescriptions under Illinois law, or a registered dietitian, must complete the required meal modification information.\"},{\"question\":\"What information must be provided about the child’s impairment and diet restriction?\",\"answer\":\"The form requires a description of the child’s physical or mental impairment and how it restricts their diet and/or access to meal programs.\"},{\"question\":\"How should foods that must be avoided be handled?\",\"answer\":\"If there are food items and/or ingredients to be avoided, the form asks to list them and provide alternatives that may be provided for those items or ingredients.\"}]","MEDICAL AUTHORITY MODIFIED MEAL REQUEST FORM - For USDA School Nutrition Programs | PDF",1791602315]