School Nutrition Program

Meal Modification Form


The School Nutrition Program's regulations require that meals offered in the schools meet the meal patterns identified in the program regulations.  Food substitutions may be made for medical or special dietary needs on a case-by-case basis if supported by a statement signed by a recognized medical authority.  A recognized medical authority may include physicians, physician assistants, or nurse practitioners.


The Authorization for Meal Modification Form on this webpage contains the required information needed to accommodate your child.  Your child's health is very important to us. Please have your medical authority complete and return the form to the school district's nurse:


Tammy Carlock, RN

499 W. Elm Street

Waverly, IL 62692


  • Be sure to sign on the parent/guardian signature line.
  •  The School Nutrition Program utilizes the Serve meal service at our elementary schools and high schools, except for Pre-Kindergarten. 
  •  Please know the School Nutrition program Parents and students are able to view school menus on your Schools website.

Your child's signed Authorization for Meal Modification Form will stay on file until the school district's school nurse until the District receives written notification from the parent/guardian to remove it. 

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