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Please note, federal regulations provide meal program Sponsors with the option to accommodate food preferences.  \n\n| SECTION 1: CHILD INFORMATION |\n| --- |\n| Child’s Name:   Date of Birth:   Facility Name:   Grade:   |\n| SECTION 2: MEAL MODIFICATION INFORMATION |\n| 1. Provide a description of how the child’s diet is restricted.\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 needed to accommodate the child’s preference. |\n| SECTION 3: SIGNATURES |\n| Parent/Guardian Name:   Relationship:   Phone:   Email:   Parent/Guardian Signature:   Date:   |\n\n\n| SEND COMPLETED FORMS TO |  |  |\n| --- | --- | --- |\n| Name:\u003Cbr>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)","cbCaievHOwhQ2Avi","https://ap.wps.com/l/cbCaievHOwhQ2Avi","pdf",1199326,"English","# SECTION 1: CHILD INFORMATION\n# SECTION 2: MEAL MODIFICATION INFORMATION\n# SECTION 3: SIGNATURES\n# Nondiscrimination Statement","[{\"question\":\"What kind of dietary needs does this form cover?\",\"answer\":\"It is used to request meal modifications for a child with a food preference that restricts their diet, excluding physical or mental impairment. Federal regulations allow sponsors to accommodate these preferences.\"},{\"question\":\"What information is required in Section 2?\",\"answer\":\"You must describe how the diet is restricted, indicate whether specific foods or ingredients must be avoided, list foods/ingredients to avoid if applicable, and provide alternatives and any additional modifications needed.\"},{\"question\":\"What does the sponsor/school section include?\",\"answer\":\"It covers administrative use such as date received, staff who received it, and follow-up communication dates. It also requires attaching documentation from relevant follow-up communications.\"}]","Preference Modified Meal Request Form - USDA School Nutrition Programs | PDF",1791602455]