Dietary Modification Request Form 25-26

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School *

Grade *

Student's Name *

Parent / Guardian Name *

Parent / Guardian Email *

Parent / Guardian Phone *

Dietary Modification Request *

Lactose Intolerance (Sub Soy Milk for Milk)

Celiac Disease (Gluten Free Diet available)

Other (Describe Below)

Required

For Other, please provide medical diagnosis and list of foods that must be omitted and suggested substitutes:

Please provide any additional information necessary, if applicable:

If additional modifications are requested please call Nutrition Services at 765.778.2152 ext. 1015

Submit

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