K-State Center for Child Development
Special Diet Notification Form
Child’s Name:
Classroom:
Parent’s Name and Phone Number:
Allergies
Please list any food allergies, intolerances that we need to be aware of.
*Please ask the Enrollment Director for a “Dr’s Note” form.
______________________________________________________________________________________________________________
_____________
If your child has an allergy, what is his or her reaction? Please be as specific as possible.
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
_____________________________________________________________________________
What is the treatment for this reaction?
*If medication is required please ask the Enrollment Director for the “Medication Dispense Authorization” form.
______________________________________________________________________________________________________________
________________________________________________________________________________________
Lifestyle Choices
Please check the lifestyle choice that applies to your child. The center will provide a substitution for your child’s meal.
Vegetarian ____Non Pork
Non Beef _____
Yogurt is ok
Yogurt is NOT ok
*The yogurt provided by the center is made with non-pork gelatin. If your child can have yogurt please check that option.
*Vegan/Organic. Our food service provider and our federal food program regulations do not allow us to provide organic or vegan meals
at this time. In addition, rice and soy milk cannot be provided unless medically required. If you would like to submit a request to prepare
and provide these meals from home, please ask the Enrollment Director for the “Vegan and Organic Request” form.
Table Food and Milk Policy
Please be aware that we serve table food and whole cow’s milk to all children 1 – 2yrs of age and 2% cow’s milk to children over 2yrs.
*If your child is less than 2yrs old and you wish for them to receive 2% milk, please ask the Enrollment Director for “Whole Milk
Waiver” form.
IMPORTANT: The K-State Center for Child Development will try in earnest to honor all meal substitution requests. However, food is
prepared by the K-State Student Union Catering kitchen, which is NOT an allergen-free facility. This means that the risk of an allergen
contaminating your child’s food is present. Also, it is possible that your child’s food may become contaminated in the classroom during
the course of a meal due to the nature of how young children conduct themselves at meal time. By signing below, you acknowledge the
possible risk of contamination and you give your permission for your child’s food allergies and/or lifestyle choices, reactions and
treatment to be posted in the classroom.
________________________________________________
Parent’s Signature
_________________
Date
Enrollment Director’s Use
 Enrollment Director to copy classroom, Food Program Director and keep original in child’s file.
 If child has allergy, Enrollment Director provides ”Drs Note” and “Medication Dispense Form” to parent.
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color,
national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue,
S.W., Washington, D.C. 20250-9410, or call (800)795-3272 (voice) or (202)720-6382 (TTY). USDA is an equal opportunity provider and employer.
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