Meal Accommodation Request
Submission of this form is a request to provide your student with medically necessary meal accommodations at both breakfast and lunch. Please note: your student must have the required documentation from a licensed medical provider (MD, DO, NP or PA-C) on file with the school nurse at their enrolled school. Documentation is not required for vegetarian or vegan requests.

To ensure that our program has the necessary items available and that staff have been adequately trained, please allow 10 school days after the receipt of this request for the accommodations to be in place. 

To cancel the meal accommodation, please submit documentation to the school nurse from your student's licensed medical provider stating that the meal accommodation is no longer medically necessary.

Sign in to Google to save your progress. Learn more
Email *
Required Documentation *
Required
Student's Name (First & Last) *
School Student Attends *
Meal Accommodation *
Required
Parent/Guardian Name (First & Last)  *
I would like to schedule a meeting with school personnel to review my student's specific dietary needs. This meeting would include the Director of School Nutrition and your student's school Nurse and Kitchen Manager. *
Required
In order for us to properly accommodate, we will need to know when your student will be eating school meals.
 
Please review and agree to the the process below:
Print menus each month from district website (both breakfast & lunch if applicable), circle the days and entrée choice that your student will be eating at school and send to your students school kitchen or email to vanessarichardson@rsu57.org

We will do our very best to accommodate with something very similar to what is on the menu but is safe for your student.

If unable to print please email a list of dates, meal period (breakfast & lunch) and entrée choice to vanessarichardson@rsu57.org

 *
Required
Questions or Comments:
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. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2)  fax: (202) 690-7442; or (3)  email: program.intake@usda.gov.(4)  This institution is an equal opportunity provider. The Maine Human Rights Act prohibits discrimination because of race, color, sex, sexual orientation, age, physical or mental disability, genetic information, religion, ancestry or national origin. Complaints of discrimination must be filed at the office of the Maine Human Rights Commission, 51 State House Station, Augusta, Maine 04333-0051. If you wish to file a discrimination complaint electronically, visit the Human Rights Commission website at https://www.maine.gov/mhrc/file/instructions and complete an intake questionnaire. Maine is an equal opportunity provider and employer.
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of RSU57. Report Abuse
Google Forms