Special Dietary Needs Form

Students with food allergies, food intolerances, or medical conditions that affect a major life or bodily function are permitted to request meal modifications. A United States Department of Agriculture (USDA)-required form, which must be completed and signed by a physician, is available by clicking the link below. This form is also available from your child’s school nutrition services coordinator. Parents are encouraged to make their child’s school office aware of all student allergies and have open communication with the school nutrition staff.

 Download the Special Dietary Needs form. This form will need to be completed by a licensed physician (M.D., ARNP, D.O., or P.A.) to document any special dietary needs that are required due to a medical disability. Any future changes to the student’s special dietary needs will require an updated form that is also signed by a licensed physician (M.D., ARNP, D.O., or P.A.).

Completed Special Dietary Needs forms should be returned to:

Nutrition Services Center
360 Farmington Avenue
Louisville, KY 40209

Email: nutritionspecialdiets@jefferson.kyschools.us

Fax: (502) 485-6494

Caution: Common food allergen triggers—including dairy, eggs, fish, milk, nuts, soy, and wheat—may have come in contact with some or all JCPS foods due to cross-contamination in manufacturing or preparation.

Still have questions?

Contact Us:

(502) 485-6480

Food Preferences

USDA Child Nutrition Programs are federal programs that require accommodations to be made if a child has a documented disability. Schools do not make modifications to meals based solely on food preferences. However, most food preferences may be able to be accommodated by making choices that are already available on the daily serving line. If you would like to make the nutrition staff aware of your child’s personal or cultural food preferences, you may fill out the top half of the Special Dietary Needs Form. For personal and cultural preferences, a physician’s signature is not needed.

Discrimination Grievance Handbook (PDF)

Other health forms that may be needed can be found on the Health Services webpage.

Two of these forms are included below: