Special Diets and Allergies
Special Diets and Allergies
If your child has allergies and requires a special diet or needs modified meals due to a medical condition, please complete the Medical Statement for Student’s Requiring Special Meals. This form is required before we can provide your student with anything other than the standard meal and also before we can omit/eliminate items from their meal. We cannot flag an account to warn the cashier of a medical condition until this form is on file in our office. For the protection of your student, it is therefore required that all meals should be supplied from home by packing a lunch until the form has been returned to the school health office. Only a licensed physician or physician’s representative may sign the medical statement. This form MUST be kept on file for all students with disabilities receiving special diet modifications and allergies. A short note from a physician on a prescription pad DOES NOT contain the required information and in addition a parent signature is required to provide alternate meals for your student. Required information includes:
- The child’s disability or food allergy
- An explanation of how the disability restricts the child’s diet
- The food or foods to be omitted from the child’s diet and the food or choice of foods that need to be substituted.
Please ensure that detailed diet information is provided on the medical statement stating the level of omission of the food allergen or foods that your child is intolerant to. This information is necessary to ensure your student is provided with the foods that are appropriate to their specific dietary restrictions. For example, if your student cannot have milk, we need to know if they cannot have milk to drink or if they cannot have any milk or dairy at all in their diet. Or, if they cannot have eggs, we need to know if it is just whole eggs (i.e. scrambled eggs) or eggs cooked in products also (i.e. cakes) Please complete the Medical Statement for Student’s Requiring Special Meals form and turn it in to your school health office. Feel free to contact our Dietitian, Julie LaSerre at 816-736-6859 for more information or how we can better meet the special diet needs of your student. If your child’s diet changes for any reason, please make sure to have your physician fill out the Discontinuation of Diet form. It is the policy of the Liberty Public School Nutrition Department to follow any medical documentation that is on file in our office. We cannot make any changes or substitutions until the proper medical form is on file.
If you have any questions, please call Julie LaSerre, RDN at 816-736-6859 or julie.laserre@lps53.org, LPSDietitian@lps53.org
Discontinuation of Diet Form
USDA Special Meals Medical Statement
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or Incident.
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 state or local agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, found online at How to File a Program Discrimination Complaint 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, Mail Stop 9410
Washington, D.C. 20250-9410; or
(2) fax: (202) 690-7442; or
(3)email: program.intake@usda.gov
This institution is an equal opportunity provider.

