Special Diet Statement Form

If you are requesting any special dietary requests for your child, please complete one of the following Special Diet Forms. These forms need to be signed and filled out by your primary care provider and parent signature to make changes in the school provided food services. 

The Special Diet Statement does not need to be renewed on a yearly basis, but must reflect the child’s current nutritional needs. If changes need to be made, please complete a new form using the same procedures.

The form gives Pine Island Schools student nutrition services direction on appropriate meal substitutions for a child's special diet (e.g. food allergies that result in severe, life-threatening (anaphylactic) reactions).

Please make sure that your child’s Special Diet Statement is sent back to our health office as soon as possible.

Click below to open the Special Diet Form:

Special Diet Statement Form