Free & Reduced Meals

Elementary School Students

• Make deliveries to office
• Teach class
• Sit by friends
• Eat lunch with teacher or principal
• Eat lunch outdoors with the class
• Have a lunch or breakfast in the classroom
• Private lunch in the classroom with a friend
• Be a helper in another classroom
• Play a favorite game
• Stickers, pencils, bookmarks
• Fun video
• Extra recess
• Walk with the principal or teacher
• Fun physical activity break
• School supplies
• Trip to treasure box filled with non-food items (stickers, tattoos, pencils, erasers, bookmarks, etc.)
• Dance to favorite music in classroom
• Paperback book
• Bank system- earn play money for privileges
• Teacher or volunteer reads special book to class
• Teacher performs special skill (singing, etc.)
• Have class outdoors
• Have extra art time
• Have “free choice” time
• Read to a younger class
• Sing a silly song together
• Be the first in line when the class leaves the room

Middle School Students

• Sit with friends
• Listen to music while working at desk
• Five-minute talk break at the end of class
• Reduced homework or “no homework” pass
• Extra credit
• Fun video
• Fun brainteaser activities
• Computer time
• Field trips
• Eat lunch outside or have class outside

High School Students

• Extra credit
• Fun video or movie
• Reduced homework or “no homework” pass
• Donated coupons to movies, stores, etc.
• Drawings for donated prizes among students who meet certain grades or other standards
• Computer time
• Listen to IPod in class

A signed waiver must be received in order to apply free/reduced reduction status to the standard registration fee even if your child receives free meals through direct certification. Please return the completed waiver to the food service director.

FREE AND REDUCED PRICE MEAL APPLICATION INFORMATION RELEASE

A La Carte items are snacks that students may purchase that are not part of a meal. They are offered to all students and are intended to compliment a meal rather than replace it. All A La Carte items we sell are approved by USDA guidelines and we have introduced more low salt and low-fat snack items during the past several years.  Please call the Food Service office to request a block on your child purchasing A La Carte items with your family account. Items may still be purchased with cash.

Food Service Contact Information

• Melissa Salbar
• Food Service Director
• Melissa.Salbar@k12.nd.us
• 701-252-1950

High School Kitchen:  701-952-4150

Middle School Kitchen:  701-952-5905

Lincoln Elementary Kitchen:  701-952-2785

Louis L'Amour Elementary Kitchen:  701-952-2734

Roosevelt Elementary Kitchen:  701-952-2395

Washington Elementary Kitchen:  701-952-5548

Wm. S. Gussner Elementary Kitchen:  701-952-3804

Children are automatically eligible to receive free school meals if they live in a household receiving Food Stamps. Therefore, you do not need to fill out an application for free/reduced meals for your children.  However, we only obtain this information from the state on a periodic basis.  Please contact the Food Service Director-Cindy Wall at 701-952-3015 or by Email, when your household becomes eligible for Food Stamps so your child(ren) can begin receiving free meals immediately. 

Parents are welcome to enjoy school lunch with your child(ren).  

Please keep in mind:

• Be sure to check in the office
• Wait for your child in the cafeteria
• You must call the office by 9:00 am, indicating you will be eating lunch that day. We must have you counted on our lunch count so that enough food is prepared for everyone.
• If you choose not to eat hot lunch, you are welcome to sit with your child for lunch or bring your own lunch.
• If you are bringing your own lunch to eat with your child, please pack healthy choices.
• Parents are discouraged from bringing meals/pop purchased from restaurants/delis.
• A variety of milk choices are available for purchase in the cafeteria. 
• Parents may check out their child(ren) for noon lunch.
• Adult lunch price is $5.00

Dear Parent/Guardian:

Children need healthy meals to learn. The Jamestown 1 School District offers healthy meals every school day. Breakfast costs $2.00-elementary, $2.10-MS/HS; lunch costs $3.10-elementary, $3.15-MS, and $3.20-HS. Your child(ren) may qualify for free meals or for reduced price meals. Reduced price is free for breakfast and $0.39 for lunch. This packet includes an application for free or reduced price meal benefits, and a set of detailed instructions. Below are some common questions and answers to help you with the application process.

WHO CAN GET FREE OR REDUCED PRICE MEALS?

• All children in households receiving benefits from Supplemental Nutrition Assistance Program (SNAP), The Food Distribution Program on Indian Reservations (FDPIR), or W-2 cash benefits are eligible for free meals.
• Foster children that are under the legal responsibility of a foster care agency or court are eligible for free meals.
• Children participating in their school’s Head Start program are eligible for free meals.
• Children who meet the definition of homeless, runaway, or migrant are eligible for free meals.
• Children may receive free or reduced price meals if your household’s income is within the limits on the North Dakota Department of Public Instruction’s Income Eligibility Guidelines. Your children may qualify for free or reduced price meals if your household income falls at or below the limits on the following chart.

Department of Public Instruction

Child Nutrition and Food Distribution Programs

NOTE: Do not allow hardship deductions from the above

Reminders

*Multiply income that is received every 2 weeks (biweekly) by 26 to arrive at annual income.

*Multiply weekly income by 52 to arrive at annual income. 

*Gross or total income must be used in determining eligibility for wage earners.

*A net loss from a business or farm may not be used to offset other income. A negative income is denoted as $0.

1. HOW DO I KNOW IF MY CHILDREN QUALIFY AS HOMELESS, MIGRANT, OR RUNAWAY? Do the members of your household lack a permanent address? Are you staying together in a shelter, hotel, or other temporary housing arrangement? Does you family relocate on a seasonal basis? Are any children living with you who have chosen to leave their prior family or household? If you believe children in your household meet these descriptions and have not been told your children will get free meals, please call or email Melissa Salbar, 701-252-1950, Melissa.Salbar@k12.nd.us
2. DO I NEED TO FILL OUT AN APPLICATION FOR EACH CHILD? No. Use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: Cindy Wall, Jamestown 1 Food Service, PO Box 269, Jamestown, ND 58402-0269
3. SHOULD I FILL OUT AN APPLICATION IF I RECEIVED A LETTER THIS SCHOOL YEAR SAYING MY CHILDREN ARE ALREADY APPROVED FOR FREE MEALS? No, but please read the letter you received carefully and follow the instructions. If any children in your household were missing from your eligibility notification, contact Cindy Wall, Jamestown 1 Food Service, PO Box 269, Jamestown, ND 58402-0269
4. CAN I DOWNLOAD/PRINT AN APPLICATION? Yes! These are available on the DPI website. Visit the Jamestown 1 Website to learn more about the online application process. Contact Cindy Wall, Jamestown 1 Food Service, PO Box 269, Jamestown, ND 58402-0269, Melissa.Salbar@k12.nd.us or 701-252-1950 if you have any questions about the online application.
5. MY CHILD’S APPLICATION WAS APPROVED LAST YEAR. DO I NEED TO FILL OUT A NEW ONE? Yes. Your child’s application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for the new school year. If you do not send in a new application that is approved by the school or you have not been notified that your child is eligible for free meals, your child will be charged the full price for meals.
6. I GET WIC. CAN MY CHILDREN GET FREE MEALS? Children in households participating in WIC may be eligible for free or reduced price meals. Please send in an application.
7. WILL THE INFORMATION I GIVE BE CHECKED? Yes. We may also ask you to send written proof of the household income you report.
8. IF I DON’T QUALIFY NOW, MAY I APPLY LATER? Yes, you may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the income limit.
9. WHAT IF I DISAGREE WITH THE SCHOOL’S DECISION ABOUT MY APPLICATION? You should talk to school officials. You also may ask for a hearing by calling or writing to Adam.Gehlhar@k12.nd.us Adam Gehlhar, Jamestown 1 Superintendent, 701-252-1950 or
10. MAY I APPLY IF SOMEONE IN MY HOUSEHOLD IS NOT A U.S. CITIZEN? Yes. You, your children, or other household members do not have to be U.S. Citizens to apply for free or reduced price meals.
11. WHAT IF MY INCOME IS NOT ALWAYS THE SAME? List the amount that you normally receive. For example, if you normally make $1,000 each month, but you missed some work last month and only made $900, put down that you made $1,000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.
12. WHAT IF SOME HOUSEHOLD MEMBERS HAVE NO INCOME TO REPORT? Household members may not receive some types of income we ask you to report on the application, or may not receive income at all. Whenever this happens, please write a 0 in the field. However, if any income fields are left empty or blank, those will also be counted as zeroes. Please be careful when leaving income fields blank, as we will assume you meant to do so.
13. WE ARE IN THE MILITARY. DO WE REPORT OUR INCOME DIFFERENTLY? Your basic pay and cash bonuses must be reported as income. If you get any cash value allowances for off-base housing, food, or clothing, it must also be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income. Do not include any combat pay resulting from deployment income.
14. WHAT IF THERE IS NOT ENOUGH SPACE ON THE APPLICATION FOR ALL MY FAMILY MEMBERS? List any additional household members on a separate piece of paper and attach it to your application. Contact Melissa Salbar, Jamestown 1 Food Service, PO Box 269, Jamestown, ND 58402-0269, 701-952-3015, or Melissa.Salbar@k12.nd.us to receive a second application if needed.
15. MY FAMILY NEEDS MORE HELP. ARE THERE OTHER PROGRAMS WE MIGHT APPLY FOR? To find out how to apply for Supplemental Nutrition Assistance Program (SNAP) or other assistance benefits, contact your local assistance office or call 701-252-9030.

If you have other questions or need help, call 701-252-1950.

(F) Fresh Fruits & Vegetable Program

The Fresh Fruit and Vegetable Program (FFVP) is a federally assisted program providing free fresh fruits and vegetables to students in participating elementary schools during the school day at times other than breakfast, lunch, or after school snack.

Administered at the state level by Child Nutrition & Food Distribution programs – the same agency that administers the National School Lunch Program – the FFVP began in 2004. Legislation in 2008 expanded the program to schools not previously authorized to participate in the program.

The United States Department of Agriculture (USDA) Food and Nutrition Service has very defined criteria for schools eligible for this program. Section 19 of the National School Lunch Act (NSLA) requires that schools with the highest free and reduced price enrollment be given priority for participation. This is the key selection criterion, which ensures that the program benefits low-income children. This criterion cannot be waived to give all schools in the state an equal chance to participate in the program.

The goal of the FFVP is to improve children’s overall diet and create healthier eating habits to impact their present and future health. The FFVP will help schools create healthier school environments by providing healthier food choices, expanding the variety of fruits and vegetables children experience, and increasing children’s fruit and vegetable consumption.

Healthy Tips for Lunches from Home

WINNING LUNCH BOX STRATEGIES: The lunch meal should contain about 1/3 of the day’s vitamins, minerals, and calories. Offer a variety of foods that include at least:

• Two servings of fruits or vegetables
• A serving of calcium fortified juice or milk
• Two or more servings of WHOLE-GRAIN bread
• Protein-lean turkey, chicken, ham, or cheese. Peanut butter if your school permits
• Please NO soda pop or candy

Dairy/Protein-rich Foods

• Low-fat string cheese
• Low-fat cottage cheese
• Low-fat yogurt
• Pudding cups
• Lean ham, turkey or roast beef
• Hard-cooked egg
• Bean dips
• Hummus

Grains

• Whole-grain bread
• Whole wheat pitas
• Baked tortilla chips
• Animal crackers
• Hard pretzels
• Rice cakes
• Whole-grain cereal
• Whole-grain mini-bagels
• Whole-grain bred sticks or crackers
• Vanilla wafers
• Low-fat/low-sugar breakfast, granola or chewy bars
• Graham crackers

Nuts*/Seeds

• Nuts
• Trail mix
• Peanut butter
• ***If no nut allergies

Fruits/Vegetables

• Grapes
• Apple slices
• Orange slices
• Mandarin oranges/tangerines
• Pears
• Bananas
• Melon balls (honeydew or cantaloupe)
• Watermelon
• Mango slices
• Fresh fruit in season (like strawberries, blueberries, cherries, peaches, apricots, nectarines, plums, kiwis, pineapple)
• Cherry tomatoes
• Broccoli florets
• Celery sticks
• Cucumber spears
• Red or green bell pepper sticks
• Dired fruit/fruit chips (like raisins, cranberries, apple rings, or banana chips)
• Fresh fruit salad or canned fruit cups
• Fresh salads (low-fat dressing packed separately)
• Applesauce

ENSURE SAFE BOX LUNCHES

Keep hot foods hot and cold foods cold. Keep cold lunches in an insulated box or bag with ice pack. Pack hot foods in a thermal container. Throw away leftover lunches. Properly clean lunch boxes often.

Please use these instructions to help you fill out the application for free or reduced price school meals. You only need to submit one application per household, even if your children attend more than one school in the Jamestown 1 School District. The application must be filled out completely to certify your children for free or reduced price school meals. Please follow these instructions in order. If at any time you are not sure what to do next, please contact 701-252-1950 or Melissa.Salbar@k12.nd.us

PLEASE US A PEN (NOT A PENCIL) WHEN FILLING OUT THE APPLICATION AND DO YOUR BEST TO PRINT CLEARLY.

Instructions for Free and Reduced Price School Meals

Ideas for Healthy Fundraising Alternatives

Fundraising Events

• Basketball tournaments
• Bowling night/bowl-a-thon
• Car wash
• Family game nights
• Fun runs
• Gift wrapping
• Golf tournament
• Jump rope-a-thon
• Lunch box auction
• Magic show
• Rent-a-teen helper (clean windows, mow lawns)
• Recycling cans/bottles/paper
• Silent auctions
• Singing telegrams
• Skate night
• Talent shows
• Treasure hunt/scavenger hunt
• Workshops/classes

Events Supporting Academics

• Science fair
• Spelling Bee

Customized Merchandise

• Bumper stickers/decals
• Cookbook made by school
• Licence plate holders
• Logo stickers
• School Frisbees
• School spirit gear
• Souvenir cups

Healthy Foods

• Fresh and exotic fruit baskets
• Frozen bananas
• Nut baskets
• Lunch box auctions
• Trail mix

Non-Food Items to Sell

• Activity theme bags
• Bath accessories
• Books, calendars
• Christmas trees
• Coffee cups/mugs
• Christmas ornaments
• Coupon books
• Emergency kits
• First aid kits
• Flowers and bulbs
• Football seats
• Garage sale
• Garden seeds
• Coloring books
• Gift baskets
• Gift certificates
• Gift items
• Gift wrap, boxes, and bags
• Greeting cards
• Holiday wreaths
• House décor
• Magazine subscriptions
• Music, videos, CD’s
• Pet treats/toys accessories
• Pocket calendars
• Raffle tickets

District Nutrition Standards for Foods and Beverages sold/served to students outside the National School Lunch and Breakfast programs during the school day (1/2 hour before school begins to ½ hour after school ends) sponsored or provided by the school district.

*Foods/Beverages outside the National School Lunch and Breakfast program include: A la carte items, vending machines, and school stores.

Fat

• ≤ 35% of total calories from fat/portion
• Trans Fat-free (≤ 0.5 g)
• ≤ 10% of total calories from saturated fat/portion

(Nuts, seeds, and reduced fat cheese are exempt from the total fat standard. They must meet all other IOM standards including saturated fat, trans fat and sodium.)

Sugar

• ≤ 35% of total calories from total sugar/portion

(100% fruits and vegetables in all forms without added sugars are exempt)

Sodium

• ≤ 200 mg/portion
• ≤ 480mg per entrée portion as served for a la carte

Calories/Portion Size

• ≤ 200 calories/portion
• A la carte items should not exceed calorie limits on comparable National School Lunch Program items

Produce and Whole Grains

• Locally grown produce will be sold where available and economical and whole grain items will be offered as available

Nutrition Standards for Beverages

• All schools may sell:
  • Plain water (with or without carbonation)
  • Unflavored low fat milk
  • Unflavored or flavored fat free milk and milk alternatives permitted by NSLP/SBP
  • 100% fruit or vegetable juice and
  • 100% fruit or vegetable juice diluted with water (with or without carbonation), and no added sweeteners.
     
• Beyond this, the standards allow additional “no calorie” and “lower calorie” beverage options for high school students.
  • No more than 20-ounce portions of:
    • Calorie-free, flavored water (with or without carbonation); and
    • Other flavored and/or carbonated beverages that are labeled to contain <5 calories per 8 fluid ounces or ≤ 10 calories per 20 fluid ounces.
• No more than 12-ounce portions of:
  • Beverages with ≤ 40 calories per 8 fluid ounces, or ≤ 60 calories per 12 fluid ounces.
     
• Sugar Sweetened Beverages
  • Elementary Schools: beverages with added caloric or non-nutritive sweeteners are prohibited
  • Middle School/High School: beverages with added calories are prohibited
     
• Fat Content of Milk
  • Only low-fat (1%) or non-fat/skim milk
     
• Portion Sizes
  • Elementary School: up to 8 ounce portions of milk and 100% juice
  • Middle School/High School: up to 12 ounce portions of milk and 100% juice
  • There is no portion size limit for carbonated or non-carbonated plain water

In 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.

Program 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.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, 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:

mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410; or

fax:
(833) 256-1665 or (202) 690-7442; or

email:
program.intake@usda.gov

This institution is an equal opportunity provider.

Non-Food Celebrations

• Plan special party games and activities
• Give children extra recess time instead of a class party. For birthdays, let the birthday child choose and lead an active game.
• Instead of food, ask parents to purchase a book for the classroom or school library in the birthday child’s name. Read it to the class or invite the child’s parents to come read it.
• Instead of a party, organize a special community service project (e.g. invite senior citizens for a program.) Involve parents in planning the project and providing needed materials
• Create a “celebrate me” book. Have classmates write stories or poems and draw pictures to describe what is special about the birthday child.
• Provide special time with the principal or another adult, such as taking a walk around the school at recess.
• Create a special birthday package.
• Let the birthday child wear a special sash and crown.
• The birthday child is the teacher’s assistant for the day, and gets to do special tasks like make deliveries to the office, lead the line, start an activity, and choose a game or story.

Nutrition Recommendations for Classroom Celebrations, Snacks, and Birthday Treats

Food Standard:

1. Fruits and/or vegetables are encouraged to be the first choice for snacks and birthday treats.
2. It is recommended that lower fat/lower sodium/ whole grain (51%) food options will be chosen to be served. (Examples include low fat yogurt, 100 calorie snack packs, baked whole grain chips, low fat ranch dressing)
3. Baked items and fried items (such as donuts) are discouraged but if they are brought to school they are encouraged to be no larger than 3 inches’ square, 2 oz muffins or 2 ½ -3“diameter cookies.

Beverage Standard:

1. 100% juice and low fat milk (skim or 1%, flavored or unflavored, soy or rice), and water (flavored or unflavored, without added sugars or caloric sweeteners) are recommended.
2. Zero calorie sports drinks, vitamin water, zero calorie iced tea or lemonade are not encouraged but allowed.
3. Every effort will be made to purchase the smallest size of beverage possible. Exceptions will be made for 16 oz. milk products, for 12 oz. 100% juice and any size of water.

**Snacks not allowed include candy and gum.

**Beverages not allowed include diet and regular soda pop, fruit drinks with less than 100% fruit juice, and energy drinks.

HEALTHY IDEAS FOR SCHOOL SNACKS AND CELEBRATIONS

• Fresh Fruit
• Fresh Vegetables
• Baked Tortilla Chips and Low Sodium Salsa
• Yogurt
• Light Buttered Popcorn
• Whole Grain Bagel with Cream Cheese
• Granola Bars and Cereal Bars (Look for whole grain)
• Trail Mix
• Pretzels
• Animal Crackers
• String Cheese
• Mini Muffins
• Graham Crackers
• Whole Grain Crackers
• Vanilla Wafers
• Saltines
• Whole Grain Fruit Bar
• Corn Nuts
• Rice Cakes
• Whole Grain Cereal
• Celery with Peanut Butter
• Apples and Caramel
• Single Serving Canned Fruit
• Dried Fruit (ex-Raisins, Banana Chips)
• Fudge Bar
• Pudding
• Frozen Yogurt
• Bottled Water
• 100% Fruit Juice
• Single Serve Skim or 1% flavored or unflavored Milk

**Snacks not allowed include candy and gum.

**Beverages not allowed include diet and regular soda pop, fruit drinks with less than 100% fruit juice, and energy drinks.

Nutrition Standards for Concessions held on School Premises Sponsored by or not Sponsored by School

(e.g., Booster Club concessions, PTO Concessions, Tailgating, Spaghetti Suppers)

Any event held on JPS premises sponsored by or not sponsored by the school must adhere to the following:

Food Standard:

1. Fruits and/or vegetables are encouraged to be offered at any location where food is served free or sold.

2. It is recommended that lower fat/lower sodium/ whole grain (51%) food options will be chosen to be served/sold. (Examples include low fat/low sodium hotdogs, low fat yogurt, 100 calorie snack packs, baked whole grain chips, low fat ranch dressing, whole grain buns)

3. Baked items are encouraged to be no larger than 3 inches square, 2 oz muffins, or 2 ½ - 3“diameter cookies.

Beverage Standard (items sold must include the following, but are not limited to):

1. 100% juice and low fat milk (skim or 1%) will be sold at all locations where juice and milk are sold/served.

2. Water must be easily accessible in pitchers, fountains, or bottles where beverages are served/sold.

3. Every effort will be made to purchase the smallest size of beverage possible. Exceptions will be made for 16 oz. milk products, for 12 oz. 100% juice and any size of water.

4. Soda pop and energy drinks are not encouraged but allowed.

Online Payments

We accept online credit/debit card payments via Infinite Campus

Cash/Check Payments

Checks are preferred and can be made payable to: Jamestown 1- Food Service Dept.  Payments should be in an envelope clearly marked with the child's first and last name.

Computer-Based Family Accounts

We utilize a computer-based accounting system that functions similar to a debit card.  Each student is given a confidential food service 4-digit number to be entered at meal time. This user-friendly system maintains the daily account balance.

Account Balances and History

You can check account balances and transaction history online at JPS Infinite Campus If the online method or app do not work for you, contact the food service director.  Students are expected to maintain a positive food service balance. Service may be suspended for delinquent accounts.

School Lunch Collection Process:

Families that are above $15.00 negative lunch balance per student will have one of the following five options:

1. Family can make a payment in full to get student account current.
2. Family can make a payment plan with food service. The district will be very flexible with payment plans, but it must be strictly adhered to.
3. Family can pack a lunch and send with their student.
4. A family can provide cash for that day’s meal. This will be accepted without regard to the negative balance.

Balance Notifications

Courtesy and negative balance notifications will be sent to all families-

• Emails will be sent to families with $15.00 or less in their account
• Low balance phone calls, text, emails and letters will be sent to families with $5.00 or less in their account

Note: Extra snack items may not be charged if a balance is due

Please make sure we have your correct contact information with your school secretary in PowerSchool in order to receive proper notifications. Demographic changes can be requested via Family Access.

Students enrolled in the Middle School and High School will be reminded that they need lunch money when their balance is negative $15.

Medical Statement for Students with Special Nutritional Needs for School Meals

When completed fully, this form gives schools the information required by the U.S. Department of Agriculture (USDA), U.S. Office for Civil Rights (OCR), and the U.S. Office of Special Education and Rehabilitative Services (OSERS) for meal modifications at school.

This form requires completion by the student's parent and by a Licensed Physician.