Ballyhenry PS - Special Diet Application Form

If your child requires a special diet, please fully complete this form and return to the school office. Please note -

- If your child requires a special diet for religious or cultural reasons or because they are vegetarian or vegan, please fully complete part A and part B of this form.

- If your child requires a special diet for medical / health reasons, please complete part A and part C of this form, in addition to a Special Diet Medical Form. Please note, special diet medical forms may be signed only by a medical consultant, GP or dietitian.

Incomplete forms will not be accepted and will be returned to parent/s or guardian/s, for completion. This may result in a delay

PLEASE NOTE - The school catering service will accommodate specific dietary needs from existing menus and ingredient range, therefore a child with a special dietary need may not always get a choice of dishes. If any specialist dietary preparations and prescription foods are required these will need to be supplied by the child's parent/s or guardian/s. The set price for school meals will remain the same in these circumstances.

PART A - Contact Details

Pupil's Name*

Pupil's D.O.B - Date Of Birth*

Current School Attending*

School Address*

Parent/s or Guardian/s Name/s*

Parent/s or Guardian/s Address*

Parent/s or Guardian/s Daytime Telephone Number*

PART B - Religious, Cultural or Vegetarian / Vegan Diet Requirement

Please specify the type of diet required*

Please list the foods to be avoided*

Please list the foods that can be used as a substitute*

Other Relevant Information

PART C - Medically Prescribed Dietary Requirement

Please indicate the type of medical condition the special diet is to be provided for (please tick all boxes that apply)

DiabetesCoeliac DiseaseChron's DiseasePhenylketonuria (PKU)

Nut AllergyDairy / Lactose IntoleranceEgg AllergyWheat Allergy

Other (please specify)

If other please list the foods to avoided and list of foods that can be used to substitute these. An additional list of food and drinks can be attached to this form.

Healthcare Professional contact Details

Contact Name*

Contact Telephone Number*

Please list the foods to be avoided*

Please list the foods that can be used as a substitute*

Does your child require any foods to have changes in texture?*

YesNo

If yes, please list any foods that need changes in texture and state the changes required.

Do you use special dietary products with your child?*

YesNo

If yes, please give further details

Do you use prescribed dietary products with your child?*

YesNo

If yes can you provide the school catering service with a small amount of prescribed products for use, in preparing diet?*

YesNo

Please give details of the product and amount

Parent / Guardian Signature*

Please Print Name*

Date*

Date