Beaufort-Jasper Eoc Head Start
Medical Diet Documentation Form
Child's Last Name:
Child's Middle Name:
Child's First Name:
What program option are you registering for?
Early Head Start
List all restricted foods:
Alternate foods or supplements to be provided in place of restricted foods (this is required when a food group is being restricted from the diet):
How long will the child require the above diet restriction/regimen?
List any vitamin/mineral supplements (i.e. Pedi sure, Ensure, Boost) or other pertinent medication the child is taking:
Is the child being followed by a Registered/Licensed Dietitian?
If yes, please list the name and phone number: