EISD Dietary Restriction and Allergy Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Dietary Restrictions/Food Allergy - Medically Necessary/Diagnosed Allergies

For a Dietary Restriction or Food Allergy to be considered "medically necessary", there MUST be an official doctor's note filed with your school nurse. There are standard and sample forms that can be obtained from your campus Nurse and filled out by your doctor. Child Nutrition will work with the parents, students, and school nurses to accommodate these dietary restrictions/food allergies to ensure proper and safe nutrition for each student. Some of these accommodations could result in an additional charge at the point of sale due to the additional cost incurred by district.

Dietary Restrictions or Religious Accommodations

Eanes ISD will make every effort to accommodate any other dietary or religious preferences/restrictions as requested by each parent or guardian. Many of these accommodations can be met with no additional charge, but some will result in an additional charge to the student at the point of sale due to the additional cost to the district. if you have any questions regarding this policy please contact our CN Dietitian, Charlotte Hachenberg, at chachenberg@eanesisd.net.

Please Fil out the form Completely and submit. MUST FILL OUT ONE FORM FOR EACH STUDENT

We will input these into your child's account as soon as Possible, please allow 3 business days for processing.

Email *

PARENT/GUARDIAN FIRST & LAST NAME - This will count as a signature and your consent to make changes to your students meal account Dietary restrictions/accommodations . *

STUDENT LEGAL NAME as listed on Birth Certificate (Please fill out separate form per each elementary student) :
*

STUDENT ID#
*

SCHOOL/CAMPUS-Where they are registered
*

STUDENT GRADE (Please fill out separate form per each elementary student)
*

FOOD ALLERGY vs. ACCOMMODATION /RELIGIOUS/OTHER- Is this dietary restriction medically necessary. To be "OFFICIALLY" considered medically necessary food allergy, you MUST have a doctors note on file with the school nurse to check "YES", if not, you MUST check "NO". If at any point you do obtain a doctors note and file it with your school nurse, you may resubmit this form with your updated response *

YES, this is a MEDICALLY NECESSARY FOOD ALLERGY

NO, this is a DIETARY ACCOMODATION/PREFERENCE, RELIGIOUS ACCOMODATION, or OTHER

Clear form

Never submit passwords through Google Forms.

This form was created inside of Eanes ISD. Report Abuse

Forms