If your child requires a special diet provided daily by the school cafeteria, a Medical Statement to Request Special Meals and/or Accommodations form must be submitted to the Child Nutrition Services department. The form must be filled out in English and signed by a U.S. licensed physician, physician’s assistant, or nurse practitioner.
To request a milk substitution due to a medical or other special dietary need, please complete the Parental Request for a Fluid Milk Substitution for School-Age Children form. Please note, this form is not intended to accommodate students who drink fluid milk substitutions, such as soy milk, due to taste preference.
Please be sure that all forms are filled out in their entirety before submission to ensure special diets are implemented in a timely manner.
Special meal accommodations and milk substitution requests must be turned in every school year; they do not roll over from the previous year.
If your student changes schools, please notify the Child Nutrition Services office.
Send all forms directly to Parisa Shukla at firstname.lastname@example.org or in person at 9739 Denni Street, Cypress, CA 90630.
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: email@example.com.
This institution is an equal opportunity provider.