Food Allergies & Dietary Needs
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. Meals cannot be served without a medically authorized diet order.
Please click the photo below to be directed to the DPI website to print a Special Dietary Request Form.
Parent/Guardian Request for Fluid Milk Substitution
School District of Janesville School Nutrition Program
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 Lactaid lactose free milk for all students with lactose intolerance or sensitivity. The School Nutrition Program also provides Kikkoman Pearl Soy Milk (plain).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:
|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|
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:
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 or Lactose Free Milk
Parent Signature: Date:
Please return this form to: School or to:
School District of Janesville
Jim Degan/School Nutrition Manager
527 S. Franklin St.
Janesville, WI 53548
OFFICE USE ONLY
Milk substitute provided? Y N Date:
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, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal
Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter 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 (2) fax: (202) 690-7442; or
(3) email: firstname.lastname@example.org.
This institution is an equal opportunity provider.