5/2010

Child Nutrition & Wellness, Kansas State Department of Education

Form 19-C

Prescribed by a Medical Authority

Medical Authority’s Name _______________________________________________________

Student’s

Name

_______________________________________________________________

School

______________________________________________________________________

I certify that the student named above is no longer in need of the previously prescribed meal

modifications effective on the following date: ________________________________________

_________________________________________________

___________________________________

Signature of Medical Authority

Date

_________________________________________________

___________________________________

Street Address

Phone

_________________________________________________

City, State, Zip

Requested by a Parent/Guardian

Name

of

Student

______________________________________________________________

School

______________________________________________________________________

I certify that the student named above is no longer in need of the previously requested

substitution for fluid cow’s milk effective on the following date: __________________________

_________________________________________________

___________________________________

Signature of Parent/Guardian

Date

_________________________________________________

___________________________________

Street Address

Phone

_________________________________________________

City, State, Zip