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?*

Center:*

Diet regiment/restriction:

List all restricted foods:

Medical Reason:

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):

Other Instructions:

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?*

Yes

If yes, please list the name and phone number:

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