Food Allergies need to be accompanied with a medical signature indicating what the allergy is and what foods might be affected. Please complete the form and return to the School Nutrition office at the Educational Services Center at 527 S. Franklin St. Janesville. Modified meals require a medically authorized diet order. 

 

Parents/guardians may request, in writing, a non-dairy fluid milk substitution for their child with a medical or special dietary need without providing a statement from a medical authority. The milk substitute requested must be nutritionally equivalent to fluid milk and meet the nutritional standards set by the United States Department of Agriculture (USDA) for Child Nutrition Programs 1 . Important note: Program operators are not required to provide substitutions and this request may be denied 2. Price, availability, purchasing requirements, and other factors will be considered for this request. Fruit juice and water do not qualify as milk substitutes.

The School District of Janesville School Nutrition program provides Soy milk for all students with lactose intolerance or sensitivity. Please inform the School Nutrition Manager at your school of this need.

A non-dairy milk substitute must, at a minimum, contain the following nutrient levels per cup (8 fluid ounces) to qualify as an acceptable milk substitution:

Nutrient	Amount	Nutrient	Amount
Protein	8 grams	Phosphorus	222 mg
Calcium	276 mg	Potassium	349 mg
Vitamin A	500 IU	Riboflavin	.44 mg
Vitamin D	100 IU	Vitamin B-12	1.1 mcg
Magnesium	24 mg

Reference: 7 CFR 210.10(d)(3) and 7 CFR 220.8(d); 2
Reference: USDA Policy Memo SP 35-2009 Q&As: Milk Substitution for
Children with Medical or Special Dietary Needs (Non-Disability)

To be completed by Parent/Guardian and returned to School Nutrition Office:

Student’s name:
School: Grade:
State the medical or dietary need that restricts the student’s diet and requires a substitute for fluid milk:

(Please circle one substitute)
Soy Milk
Parent Signature: Date:
Please return this form to: School or to:

School District of Janesville
Liz Leedle/School Nutrition Manager
527 S. Franklin St.
Janesville, WI 53548
Phone: 608-743-5153/Fax:608-743-5134

This written statement will remain in effect until the parent or legal guardian revokes such statement or
until the school discontinues the fluid milk substitution option.

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1. mail:
   U.S. Department of Agriculture
   Office of the Assistant Secretary for Civil Rights
   1400 Independence Avenue, SW
   Washington, D.C. 20250-9410; or
2. fax:
   (833) 256-1665 or (202) 690-7442; or
3. email:
   Program.Intake@usda.gov

This institution is an equal opportunity provider.