In effort to best meet your child’s dietary needs, all sections of this form must be completed in full prior to submitting it to the school. •

• The student’s parent/guardian should complete the identifying information sections at the top of the form, sign, and date the medical plan of care.

• Sections one through five must be completed by a West Virginia state licensed medical authority (Physician, MD or DO; Physician Assistant, Certified Registered Nurse Practitioner, or Dentist) It is particularly important that the medical authority list the medical diagnosis in section one. The licensed medical provider must also sign and date this form.

• Please note, a parent/guardian is not authorized to complete sections one through five. If the form is not completed by a licensed medical authority, it will be returned to you which will cause a delay in processing the request.

Once the form is completed, return it to your child’s school nurse. Please be aware that it may take up to two weeks to obtain the correct food items to meet your child’s dietary needs.

Special Dietary Needs Form

The following items meet the nutritional guidelines set forth in USDA Smart Snack Guidelines.

• Fresh Fruit Trays* (or any whole fruits of fruit cut up at the school)

• Dried Fruits (including raisins)

• Fresh Vegetable Trays* (or any vegetables cut up at the school)

• Yogurt

• String Cheese

Note the descriptions and packaging sizes given. These particular items, at the indicated package size, should fall within the guidelines. Ingredients may change so please visit Healthier Generations food calculator at https://foodplanner.healthiergeneration.org/calculator/ to check if your food item meets the USDA Smart Snack Guidelines.

Many prepackaged fruit/vegetable trays contain dips (i.e. caramel, ranch) that typically do not meet the guidelines.

Please note that our county wellness policy allows for ONE food item at a celebration to be exempt from having to meet the USDA Smart Snack Guidelines.

• Animal Crackers – 1oz package

• 100 Calorie – Chocolate Caramel

• 100 Calorie – Cinnamon Coffee Cakes

• 100 Calorie Right Bites – Chips Deluxe – Chocolate Chip Cookies

• 100 Calorie – Thin Crisps Oreo

• 100 Calorie – Thin Crisps Cookie Crisps Chips Ahoy!

• 100 Calorie – Toasted Chips – Baked Snack Crackers

• Pop-Tarts Mini Crisps – Frosted Brown Sugar Cinnamon

• Pop-Tarts Mini Crisps – Strawberry Wafer Cookies Mini 1 oz

• Goldfish Crackers

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  100 Calorie Cheddar Goldfish

• Goldfish Crackers –

  100 Calorie Goldfish Colors

• Goldfish Crackers –

  100 Calorie Pretzel Goldfish

• Chewy 90 Calorie Granola Bars – Chocolate Chunk

• Chewy 90 Calorie Granola Bars – Oatmeal Raisin

• Chewy 90 Calorie Granola Bars – Strawberry Vanilla

• Graham Snacks – Chocolate .75 oz package

• Graham Snacks – Cinnamon - .75 oz package