DATE: _____________________
SCHOOL NAME: ________________________________
STUDENT ID #______________________
STUDENT NAME: ___________________________________________________________
GRADE: __________________________
PARENT EMAIL: ____________________________________________________________
PARENT PHONE: ____________________
Food Allergy Management – Life threatening food allergies or special dietary needs you would like to document on your child’s meal account must be
clearly communicated through the school nurse. Please reference the Food Allergy Management Plan online for more information.
ALA CARTE RESTRICTIONS – Students are permitted to use cash or funds from their meal account to purchase ala carte items, a second meal,
entrée and/or milk. Students are not permitted to charge ala carte items when there is no money in their meal account. Students in preschool – 6 grade
are limited to two ala carte snacks and one ala carte beverage per day. Jr. High and Sr. High students do not have any item or ala carte spending limits on
their meal account. If you would like to place restrictions on your child’s meal account or remove the two ala carte items per day restriction from your
preschool–6 grade student’s meal account, this form must be completed and returned to school. Please note this restriction will carry over to future
school years unless a request in writing is received to remove the restriction.
Ala Carte Purchases are not to exceed $________ per
Do not limit my elementary or preschool student’s ala carte purchases.
My child is not permitted to purchase the following ala carte items: ________________________________________________________
--OR-No Ala Carte Snacks (food items)
No Ala Carte Beverages
No 2 Entrée purchase (extra slice of pizza or extra order of chicken nuggets)
No Second Meal Purchase
MEAL & CHARGE RESTRICTIONS – Unless specified below, Nutrition Services will approve meal charges and will provide a school meal
when students do not have a packed meal from home or the funds to pay for a school meal, as Nutrition Services believes that the child
will otherwise not receive a meal unless one is provided by Nutrition Services.
To place a note on your child’s account that restricts meal charges, this form must be completed. When this restriction is placed on your child’s account,
Nutrition Services will not provide a meal for your child when there are no funds on the account and you will need to make other arrangements to feed
your child. To approve any meal charges after this restriction is in place, you must notify the kitchen. Please note this restriction will carry over to future
school years unless a written request is received to remove it.
By checking the following boxes, I am requesting that Nutrition Services refuse to serve my child:
Absolutely No Charges on my child’s account.
I understand and agree with the following:
Unless there are funds on the account, I understand that my child will not be offered a school lunch, after this form is submitted and
the restriction is in place. I agree it is my responsibility to notify the kitchen to lift the restriction, if necessary.
I understand that my child could take a meal before a Nutrition Services employee is able to intervene. If this occurs, I agree to pay this
meal charge, as the food cannot be re-served and will result in a loss to the school lunch program.*
*Please help to prevent avoidable charges by frequently checking your child’s meal account balance and preparing your child to make alternate
plans when there are no funds or a packed meal from home.
**NOTE – Meal account restrictions are subject to approval by Nutrition Services before your child’s account will be restricted. To confirm that Nutrition
Services acts in accordance with your intentions, contact Sarah Renz at (513) 831-5030 for assistance.
This form must be signed and returned to:
Nutrition Services Department
777 Garfield Avenue
Milford, OH 45150
Telephone: (513) 831-5030; Fax: (513) 831-6448
Parent’s Name
Notes Section was updated with the Date Restriction was placed on account
Parent’s Signature
Noted in Special Message Section
Y:\Nutrition Services\Dietary Restrictions\MEAL ACCOUNT RESTRICTION FORM\Meal Account Restriction Form 15-16.docx
Restriction Entered in Meals Plus