Food Substitution Request Form

Food Substitution Request Form

2024-2025
NUTRITION IS ONLY ACCEPTING FOOD SUBSTITUTION REQUESTS FOR THE 2023-2024 SCHOOL YEAR AT THIS TIME.

NUTRITION WILL BEGIN ACCEPTING FOOD SUBSTITUTION REQUESTS FOR THE 2024-2025 SCHOOL YEAR BEGINING 7/22/24
This form is used for children who are enrolled at or enrolling into Albina Head Start or Albina Early Head Start who need a Food Substitution or Infant Formula. This form can be completed by Albina Head Start Staff OR by the Parent/Guardian.

Filling out this form does not mean that the Food Substitution/Infant Formula requested has been APPROVED or will be provided.

After filling out this form a member of the Albina Head Start Nutrition team will follow up with the Parent/Guardian, and Albina Staff, to complete the necessary documentation for the requested food substitution.

For more information about Albina Head Start's Food Substitution Policy click the triangle below.

Albina Head Start Food Substitution Policy
Albina Head Start Food Substitution Policy
Albina Head Start and Albina Early Head Start comply with all Federal Statutes and subsequently derived Head Start Performance Standards that apply to child nutrition. Albina follows the USDA/CACFP meal pattern requirements and quantity guidelines. This includes providing, within the pattern and quantity requirements, appropriate food substitutions and or modifications to meet the needs of children with individual special health needs, allergies, intolerances, and/or disabilities that impact nutrition. This also includes considering ethnic, cultural, religious and individual family foodways.

Albina Head Start and Albina Early Head Start does not serve, Pork or Pork products, Fish or products containing nuts.

Only food approved by the Registered Dietitian and provided by a licensed food vendor will be served to children enrolled in Albina Head Start or Early Head Start.

Parent/Guardians may not send/provide any food or drink for children including party foods for celebration such as holidays, birthday parties or end of the school year celebration.
CACFP Child Meal Pattern Chart English Spanish

CACFP Infant Meal Pattern Chart English Spanish

ODE Requesting Meal Accommodations

Who is Completing this Form
Who is completing this form?*

PERSON COMPLETING FORM BASIC INFORMATION
AHS Staff: You will need to have access to ChildPlus when completing this form.
Your Name*

First NameLast Name
Your Email Address*
example@example.com

CHILD INFORMATION
Child Information
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date

CHILD INFORMATION AHS STAFF
Child's ChildPlus ID Number*
Program Child is Enrolled/Enrolling In*
School Year the Request is for*
NUTRITION IS ONLY ACCEPTING FOOD SUBSTITUTION REQUESTS FOR THE 2023-2024 SCHOOL YEAR AT THIS TIME.

NUTRITION WILL BEGIN ACCEPTING FOOD SUBSTITUTION REQUESTS FOR THE 2024-2025 SCHOOL YEAR BEGINING 7/22/24

PLEASE EXIT OUT OF THIS FORM.

CONTACT NUTRITION@ALBINAHEADSTART.ORG IF YOU HAVE ANY QUESTIONS
Child's Classroom*
Child's Caseload*

PARENT/GUARDIAN INFORMATION
Parent/Guardian Information

PARENT/GUARDIAN INFORMATION AHS STAFF
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email Address*
example@example.com

PARENT/GUARDIAN INFORMATION PHONE
Parent/Guardian Phone Number*
Please enter a valid phone number.

AHS STAFF LANGUAGE INFORMATION
Parent/Guardian's Primary Language*
Other Language*
Does the Parent/Guardian need Translation assistance?*

YesNo, they are proficient at speaking and understanding EnglishNo, they have a family member who can assist with translation.
Name of Family Member who can assist with translation*

CLICK NEXT PAGE 1
Click NEXT below to continue

NON-DISCRIMINATON STATEMENT PAGE 1
This institution is an equal opportunity provider. Click here for more info.

HIDE PAGE 1
HIDE PAGE 1 LANGUAGE TEXT
HIDE PAGE 1 PG Email
example@example.com

Nutritionally Equivalent Milk Substitute
A Nutritionally Equivalent Milk Substitute is defined as a non-dairy substitute that is nutritionally equivalent to cow’s milk, as outlined in the National School Lunch Program (NSLP) regulations at 7 CFR 210.10(d)(3). Not all non-dairy substitutes will meet this requirement.

Albina Head Start offers the following approved Nutritionally Equivalent Milk Substitutes
- Kirkland Signature Organic Soy Non-Dairy Beverage, Original
- Kirkland Signature Organic Lactose Free 2% Reduced Fat Milk
Nutritionally Equivalent Milk Substitute Requested*

MILK NONE OF THE ABOVE
Other Milk Substitutes
Other Milk substitutes will ONLY be approved if the child has a life-threatening allergy to BOTH dairy products and soy products, and no nutritionally equivalent substitute for milk is available, as supported by a *Medical Statement to Request Special Meals and/or Accommodations completed by a physician.
- Albina Head Start and Early Head Start will NOT provide any alternative milks such as almond milk, goat’s milk, hemp milk etc. due to not fulfilling the nutritional requirements.
- Nut milks such as almond, hazelnut, walnut etc. will NOT be allowed in any classrooms.
*A written note with the following information can be used in lieu of a Medical Statement:
- The participant’s major life activity or major bodily function affected by the physical or mental impairment restricting the diet
- An explanation of what needs to be done to accommodate the disability
- The food(s) to be omitted from the participant’s diet or other dietary accommodations to be made
- The food(s) to be substituted when items are omitted from the diet.
If the Doctor’s note does not contain all of the above information, Albina Head Start and Early Head Start may request more information or that a Medical Statement to Request Special Meals and/or Accommodations form is completed.
AHS STAFF: If you do not know the answer to the question below write N/A in the box.
What Other Milk is being Requested*

NON-DISCRIMINATON STATEMENT PAGE 3
This institution is an equal opportunity provider. Click here for more info.

Other Non-Medical Meal Accommodation
What food can the child NOT consume/have*
BE AS SPECIFIC AS POSSIBLE
examples:

No Eggs, No Dairy, No Cheese, No Pork

NON-DISCRIMINATON STATEMENT PAGE 4
This institution is an equal opportunity provider. Click here for more info.

Medication
Does the child require medication to be IN THE CLASSROOM for any of the substitutions requested?*
IF CHILD DOES NOT REQUIRE MEDICATION IN THE CLASSROOM CHOOSE NO.
Medication includes anything that is over the counter or prescribed by a physician.

Examples:
- EpiPen (Epinephrine)
- Allergy Medications (Benadryl, Zyrtec, etc.)
- Creams/Lotions (Hydrocortisone, Aquaphor, Aloe Vera, Calamine, Vaseline etc.)
AHS STAFF: If you do not know the medication needed pleas type N/A into the question box below
List the Medication the Child needs IN THE CLASSROOM and what the medication is for*
BE AS SPECIFIC AS POSSIBLE

NON-DISCRIMINATON STATEMENT PAGE 7
This institution is an equal opportunity provider. Click here for more info.

Infant Formula Request
Albina Early Head Start provides the following 2 formulas:
- Similac Advanced Ready-to-Eat
- Gerber Good Start Soy Ready-To-Eat
Parents may also provide expressed Breast Milk, or Breast Feed while in our classrooms.
Formula Requested for Child*

NON-DISCRIMINATON STATEMENT PAGE 8
This institution is an equal opportunity provider. Click here for more info.

Submit Form

AHS STAFF SUBMIT
Thank you {SUBMITTERNAME} for completing the Food Substitution Request Form.

After you click SUBMIT below you will receive an email confirming your submission of this form.

Please let {PARENTGUARDIANNAME} know that {NUTTEAMCONTACTTEXT} will be reaching out to them soon to follow up regarding the Food Substitutions requested.

We will also send an email to {HIDECLASSROOMCASELOAD} to let them know about the request as well.

If you or {PARENTGUARDIANNAME} have any questions or concerns please do not hesitate to reach out to {NUTCONTACTINFO}.
Please let {PARENTGUARDIANNAME} know that {NUTTEAMCONTACTTEXT} will be reaching out to them soon to follow up regarding the Food Substitutions requested.

If you or {PARENTGUARDIANNAME} have any questions or concerns please do not hesitate to reach out to {NUTCONTACTINFO}.

NON-DISCRIMINATON STATEMENT PAGE 8
This institution is an equal opportunity provider. Click here for more info.
Should be Empty:

Child's Name	{CHILDNAME}
Child's Date of Birth	{CHILDDOB}
Child's ChildPlus ID Number	{CHILDCPID}
Program Child is Enrolled/Enrolling In	{CHILDPROGRAM}
Child's Classroom/Caseload	{HIDECLASSROOMCASELOAD}
Parent/Guardian Name	{PARENTGUARDIANNAME}
Parent/Guardian Email Address	{PARENTGUARDIANEMAIL}
Parent/Guardian Phone Number	{PARENTGUARDIANPHONE}
Parent/Guardian Primary Language	{HIDEGP1LANGTEXT}
Meal Accommodation(s) Requested	{HIDESUBTYPETEXT}

Child's Name	{CHILDNAME}
Child's Date of Birth	{CHILDDOB}
Child's ChildPlus ID Number	{CHILDCPID}
Program Child is Enrolled/Enrolling In	{CHILDPROGRAM}
Child's Classroom/Caseload	{HIDECLASSROOMCASELOAD}
Parent/Guardian Name	{PARENTGUARDIANNAME}
Parent/Guardian Email Address	{PARENTGUARDIANEMAIL}
Parent/Guardian Phone Number	{PARENTGUARDIANPHONE}
Parent/Guardian Primary Language	{HIDEGP1LANGTEXT}
Does the Parent/Guardian need Translation assistance?	{PGTRANSLATION}
Meal Accommodation(s) Requested	{HIDESUBTYPETEXT}

Child's Name	{CHILDNAME}
Child's Date of Birth	{CHILDDOB}
Child's ChildPlus ID Number	{CHILDCPID}
Program Child is Enrolled/Enrolling In	{CHILDPROGRAM}
Child's Classroom/Caseload	{HIDECLASSROOMCASELOAD}
Parent/Guardian Name	{PARENTGUARDIANNAME}
Parent/Guardian Email Address	{PARENTGUARDIANEMAIL}
Parent/Guardian Phone Number	{PARENTGUARDIANPHONE}
Parent/Guardian Primary Language	{HIDEGP1LANGTEXT}
Does the Parent/Guardian need Translation assistance?	{PGTRANSLATION}
Name of Family Member who can assist with translation	{PFFMTRANSLATIONHELP}
Meal Accommodation(s) Requested	{HIDESUBTYPETEXT}

Child's Name	{CHILDNAME}
Child's Date of Birth	{CHILDDOB}
Parent/Guardian Email Address	{PARENTGUARDIANEMAIL}
Parent/Guardian Phone Number	{PARENTGUARDIANPHONE}
Meal Accommodation(s) Requested	{HIDESUBTYPETEXT}

Food Substitution Request Form

Albina Head Start Food Substitution Policy

Child Information

Parent/Guardian Information

Food Substitution Request

Nutritionally Equivalent Milk Substitute

Other Milk Substitutes

Other Non-Medical Meal Accommodation

Reason for Substitution(s)

Milk Substitution Request

Other Milk Substitutes

Other Non-Medical Meal Accommodation

Medical Meal Accommodation

Medication

Infant Formula Request

Other Formula Request

Powdered Formula Request

HIDE PAGE 9

Submit Form