HCS Medical Plan of Care for School/Site Food Service

Medical Plan of Care for School/Site Food Service
This form lets parents and guardians complete the student and needs portions online. After filling it out, the form must be printed, signed by the student’s physician or medical authority, and turned in to the school.
Student's Name*
First Name, Last Name
Date of Birth*

MonthDayYear
Date
Grade Level / Classroom*
Name of School Site*
WVEIS Number
Name of Parent / Guardian*
First Name Last Name
Parent / Guardian Phone Number*
Please enter a valid phone number.
Today's Date*

MonthDayYear
Date
Provide an explanation below of how the childs physical or mental impairment restricts the childs diet*
Describe the specific diet or necessary modifications prescribed by the state licensed medical authority to accommodate the childs needs*
List the food or foods to be omitted please be specific and recommended alternatives if appropriate Foods to be omitted*
Suggested Substitutions*
Indicate texture modifications, if applicable

Chopped/Cut into bite-sized piecesDicedFinely GroundPureedOther
List any required special adaptive equipment
DOWNLOAD AND PRINT THIS FORM
Please click DOWNLOAD AND PRINT below to download the PDF with your student's information. Please print one form for each medication.
Should be Empty:

Medical Plan of Care for School/Site Food Service