ࡱ> O abjbj22 ;PePe~ mmm8;rY4]':'' :::::::$>@ ;Qm';'"]''' ;^;A/A/A/'R8(m:A/':A/A/:I4,U40z (^u4 :t;0;4RBg(pB44Bmo5d''A/''''' ; ;+j''';''''B''''''''' : California Department of Education Child Nutrition Programs Nutrition Services Division CNP -925 (Rev. 8/17) Page 1 MEDICAL STATEMENT TO REQUEST SPECIAL MEALS AND/OR ACCOMMODATIONS 1. School or Agency2.  Site Name3. Site Phone Number4. Name of Child or Participant 5. Age or Date of Birth 6. Name of Parent or Guardian 7. Phone Number 8. Description of Child or Participant s Physical or Mental Impairment Affected:9. Explanation of Diet Prescription and/or Accommodation to Ensure Proper Implementation: 10. Indicate Food Texture for Above Child or Participant:  FORMCHECKBOX  Regular  FORMCHECKBOX  Chopped  FORMCHECKBOX  Ground  FORMCHECKBOX  Pureed11. Foods to be Omitted and Appropriate Substitutions: Foods To Be Omitted Suggested Substitutions 12. Adaptive Equipment to be Used:13. Signature of State Licensed Healthcare Professional*14. Printed Name15. Phone Number 16. Date  *For this purpose, a state licensed healthcare professional in California is a licensed physician, a physician assistant, or a nurse practitioner. The information on this form should be updated to reflect the current medical and/or nutritional needs of the participant. INSTRUCTIONS 1. School or Agency: Print the name of the school or agency that is providing the form to the parent. 2. Site: Print the name of the site where meals will be served. 3. Site Phone Number: Print the phone number of site where meal will be served. 4. Name of Child or Participant: Print the name of the child or participant to whom the information pertains. 5. Age of Child or Participant: Print the age of the child or participant. For infants, please use date of birth. 6. Name of Parent or Guardian: Print the name of the person requesting the child or participants medical statement. 7. Phone Number: Print the phone number of parent or guardian. 8. Description of Child or Participants Physical or Mental Impairment Affected: Describe how the physical or mental impairment restricts the child or participants diet. 9. Explanation of Diet Prescription and/or Accommodation to Ensure Proper Implementation: Describe a specific diet or accommodation that has been prescribed by the state healthcare professional. 10. Indicate Texture: If the child or participant does not need any modification, check Regular. 11. Foods to be Omitted: List specific foods that must be omitted (e.g., exclude fluid milk). Suggested Substitutions: List specific foods to include in the diet (e.g., calcium-fortified juice). 12. Adaptive Equipment to be Used: Describe specific equipment required to assist the child or participant with dining (e.g., sippy cup, large handled spoon, wheel-chair accessible furniture, etc.). 13. Signature of State Licensed Healthcare Professional: Signature of state licensed healthcare professional requesting the special meal or accommodation. 14. Printed Name: Print name of state licensed healthcare professional. 15. Phone Number: Phone number of state licensed healthcare professional. 16. Date: Date state licensed healthcare professional signed form. Citations are from Section 504 of the Rehabilitation Act of 1973, Americans with Disabilities Act (ADA) of 1990, and ADA Amendment Act of 2008: A person with a disability is defined as any person who has a physical or mental impairment which substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such an impairment. Physical or mental impairment means (a) any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory; speech; organs; cardiovascular; reproductive, digestive, genitourinary; hemic and lymphatic; skin; and endocrine; or (b) any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. Major life activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. Major bodily functions have been added to major life activities and include the functions of the immune system; normal cell growth; and digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions. Has a record of such an impairment means a person has, or has been classified (or misclassified) as having, a history of mental or physical impairment that substantially limits one or more major life activities.     California Department of Education Child Nutrition Programs Nutrition Services Division CNP -925 (Rev. 8/17) Page 2 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 theUSDA Program Discrimination Complaint Form (AD-3027) found online at  FPRx( n p r µϨό}n_VNF:h%MhJ5:EHh%Mho5h%Mhcz5h%MhoCJh%Mh"CJaJmH sH h%Mh8CJaJmH sH h%Mh_CJaJmH sH h%Mh*cCJaJmH sH h%MhgCJmH sH h%MhljFCJmH sH h%MhtoCJmH sH h%Mh_CJmH sH h%MhLkCJmH sH h%MhLkCJh%MhplkCJh%Mh_CJhLkhLkCJx( r $IfgdljF $Ifgd* $xa$gdU gdLk  !1)gdLkr v x z  " $ & ( Ƽִִ֬}uִme[h%Mhb@5CJh%Mh<5h%Mh|5h%Mho5.jh%Mhb@5:OJPJQJU^Jo(h%Mhb@5:h%MhP5:CJ\h%Mh"5h%MhljF5h%MhP5CJh%Mh_5h%Mh*5h%Mh}`]5.jh%MhP5:OJPJQJU^Jo(h%MhP5:! & ( X Z tkkkk $Ifgd}`]kd$$IflF%H|)# 4 0)6    4 laytyp( , . 4 6 V Z \ ^ ` b d l n r t ~ vldWOوh%Mh"5jh%MhJ5Uh%MhP5h%Mho5CJh%MhJ5:h%MhJ5h%MhljF5.jh%MhJ5:OJPJQJU^Jo(h%MhP5:h%Mhb@5:h%Mhb@5:CJ\h%Mh_5h%Mho5h%Mh}`]5+jh%Mhb@5OJPJQJU^Jo(h%Mhb@5Z \ ~~~~ $Ifgd}`]xkd$$Ifl0H|)4 0)64 laytyp   $ & * , 8 : N P ^ ` b d f h Ȳ~tj~~~~~`VNh%Mh`5h%Mh7 '5^Jh%Mh;pi5^Jh%Mh_5^Jh%Mh*5^Jh%Mh?5^Jh%MhljF5^Jh%Mho5^Jh%Mho5^Jh%MhW5PJ^J+jh%Mho5OJPJQJU^Jo(h%Mhb@5h%MhH"j5h%Mho5:CJ\h%MhJ5CJh%Mho5h%Mh}`]5 b ~ $Ifgd*xkd,$$IflU0H|)4 0)64 laytypb d     x($Ifgd $IfgdNhkd$$Ifl4E|))0)64 laf4ytkPh j    ѷyoeoe[Qe[[h%Mh5^Jh%Mho5^Jh%MhljF5^Jh%MhW5^Jh%Mho5^Jh%MhT5^Jh%MhS 0J5:^Jh%Mho0J5:^Jh%MhljF0J5:^Jh%Mho0J5:^Jh%Mho5PJ^Jh%MhljF5PJ^Jh%MhW5PJ^J+jh%Mho5OJPJQJU^Jo(   " $ & ( * 8 : < D F R T V \ ^ h j r z ñӝӝ}umfYQh%Mho\jh%MhoU\ h%Mh>h%Mh= ;5h%Mh_5h%Mh*5h%Mh5h%Mho5h%MhljF5h%Mh+T5h%MhljF5PJ^J"h%Mh_5OJPJQJ^Jo(h%Mh`5h%MhH"j5h%Mho5h%Mho5:CJ\h%Mh7 '5CJ\h%Mho5CJ\ d o  .<$If^gd $Ifgd> $Ifgd= ;hkdB$$Ifl4|))0)64 laf4ytkP   " $ 0 2 4 P R T V b d f h j p Ƹ㦖Ʈ㦆ƮvƮiaYQh%Mh_5h%MhH"j5h%Mho5h%Mho5:CJ\j%h%MhoU\jh%MhoU\j=h%MhoU\h%Mho\h%MhoCJ\h%Mh_5CJ\aJh%Mho5CJ\aJjh%MhoCJU\jh%MhoU\jh%MhoU\d f 2p P$If^gd $IfgdT $IfgdThkd$$Ifl4u|))0)64 laf4yt= ;p r | ~ 024X|r|jbh%Mh`5h%MhH"j5h%MhCJ\h%MhCJ\h%Mho5:CJ\h%Mho6CJ\]h%Mho5CJ\h%MhoCJ\h%Mho5CJ h%MhTh%MhT5h%Mho5h%Mhm75h%Mh145h%Mho5h%MhljF5h%MhN52468:<> <$Ifgdhkd $$Ifl4|))0)64 laf4ytyp>@BDFHJK@@@@@ <$Ifgdkd$$Ifl4DrV`'|)``v`0)64 laf4yt1QJLNPRTVK@@@@@ <$Ifgdkd$$Ifl4rV`'|)  v 0)64 laf4yt1QVXZ\^`bK@@@@@ <$Ifgdkd'$$Ifl4:rV`'|)  v 0)64 laf4yt1QbdfhjlnK@@@@@ <$Ifgdkd] $$Ifl4rV`'|)  v 0)64 laf4yt1QnprtvxzK@@@@@ <$Ifgdkd $$Ifl4rV`'|)  v 0)64 laf4yt1Qz|~K@@@@@ <$Ifgdkd $$Ifl4rV`'|)  v 0)64 laf4yt1QK@@777 $Ifgd <$Ifgdkd $$Ifl4rV`'|)  v 0)64 laf4yt1Q@7 $Ifgdokd5$$Ifl4rV`'|)  v 0)64 laf4yt <$Ifgd 6LNPRTVXZfhjrtvxz|ɹٯ٧ѧѧѧُُh%Mh"5h%Mhd5h%Mh]\5h%Mh`5h%MhH"j5h%MhoCJ\h%MhS 5h%Mho5h%Mh+T5h%MhljF5h%Mho5h%MhN5+jh%Mho5OJPJQJU^Jo(0Pr|k|kx($If^gd $IfgdN $IfgdljF $Ifgdohkdy$$Ifl4|))0)64 laf4yt|3:<QSUVhijkƾxxndSEh%MhNES5CJ\aJ jh%MhdUmHnHuh%MhY5\h%Mh< 5\h%Mh d5\h%MhH"j5\h%Mh)9J5\h%Mhd5\h:jXhd5CJ\h%MhoCJ\h%Mho5h%MhN5+jh%Mho5OJPJQJU^Jo(h%Mh`5h%MhH"j5h%Mhd5h%Mho5CJ\j^M:2dgdNESx]^`gd:jX]^`gdNESkd$$Ifl4 \%D%|) c   8 0)64 laf4ytljF %/YZ[^ĴtfXfJ:h%Mha5CJ\^JaJh%Mh4ZjCJ\^JaJh%Mh_CJ\^JaJh%MhWxCJ\^JaJh%Mh^,5CJ\^JaJh%MhX5CJ\^JaJh%Mh_5CJ\^JaJh%Mh*5CJ\^JaJh%MhWx5CJ\^JaJh%MhgCJ\^JaJh%MhqCJ\aJh%MhYM5\h%Mh4Zj5\h%MhY5CJ\aJZ[\]FG :8d<^`8gd|, :8d^`8gda :8^`8gda :8d<^`8gd[ qd^`qgd[ $da$gd<^bd{Ķzj\L<h%Mhy5CJ\^JaJh%MhWx5CJ\^JaJh%MhzCJ\^JaJh%MhSa5CJ\^JaJh%MhT5CJ\^JaJh%Mhg5CJ\^JaJh%MhaCJ\^JaJh%MhgCJ\^JaJh%MhpVCJ\^JaJh%MhCJ\^JaJh%MhWxCJ\^JaJh%Mh_5CJ\^JaJh%Mh5CJ\^JaJ *9:[\]`deghp{|𢔆xjxZJ::h%Mh5CJ\^JaJh%Mhy5CJ\^JaJh%Mhg5CJ\^JaJh%MhaCJ\^JaJh%MhgCJ\^JaJh%MhzCJ\^JaJh%Mh_CJ\^JaJh%MhWxCJ\^JaJh%Mh_5CJ\^JaJh%Mh*5CJ\^JaJh%Mhu5CJ\^JaJh%MhSa5CJ\^JaJh%MhWx5CJ\^JaJ|}!%02EƶzjjZLh%MhxS1CJ\^JaJh%Mh7p5CJ\^JaJh%Mh^,5CJ\^JaJh%Mhy5CJ\^JaJh%MhSa5CJ\^JaJh%MhaCJ\^JaJh%MhgCJ\^JaJh%MhWx5CJ\^JaJh%Mh_CJ\^JaJh%MhuCJ\^JaJh%MhWxCJ\^JaJh%MhQ5CJ\^JaJEFGJKPQVXbóãyi[M[?[h%MhSa5CJ^JaJh%Mhy5CJ^JaJh%Mh|,5CJ^JaJh%Mh|,5CJPJ^JaJh%Mh|,CJ\^JaJh%MhCJ\^JaJh%MhWxCJ\^JaJh%Mh_5CJ\^JaJh%MhSa5CJ\^JaJh%Mh5CJ\^JaJh%MhT5CJ\^JaJh%MhaCJ\^JaJh%MhCJ\^JaJ,23457C㹫seWGh%Mhz5CJ\^JaJh%MhaCJ\^JaJh%MhzCJ\^JaJh%MhaCJ\^JaJh%Mhj CJ\^JaJh%Mhn#zCJ\^JaJh%MhgCJ\^JaJh%Mh|,CJ\^JaJh%MhS aCJ\^JaJh%Mhy5CJ^JaJh%MhSa5CJ^JaJh%Mh|,5CJ^JaJh%Mhn#z5CJ^JaJ34\] yb d<^`gd[ 8d<^`8gd[ 8d^`8gda :8d<^`8gd[ :8d<^`8gdz :8d^`8gda :8d<^`8gd|,CDFGKLXY\]_`mnqwx~´¦zl^P^h%MhzCJ\^JaJh%Mh14CJ\^JaJh%MhaCJ\^JaJh%Mh5CJ\^JaJh%Mh4SICJ\^JaJh%MhVCCJ\^JaJh%MhCJ\^JaJh%MhICJ\^JaJh%MhaCJ\^JaJh%MhSa5CJ\^JaJh%Mhz5CJ\^JaJh%Mhy5CJ\^JaJ[\]^_`aghijkuvƹƬƒwi[wiwNNANh%Mh_CJ^JaJh%Mh{JCJ^JaJh%Mh[5CJ^JaJh%Mhy5CJ^JaJh%MhSh5CJ^JaJh%MhvQ#CJ^JaJh%MhzCJ^JaJh%MhaCJ^JaJh%Mh14CJ^JaJh%Mh_CJ^JaJh%MhShCJ^JaJh%Mh^,CJ^JaJh%MhSa5CJ\^JaJh%MhI5CJ\^JaJ  !"#%./789;<?BDlȻȻȔyky]O]Ok]Շh%Mhy5CJ^JaJh%Mhu5CJ^JaJh%MhSa5CJ^JaJh%MhvQ#5CJ^JaJh%MhvQ#CJ^JaJh%MhaCJ^JaJh%Mhso!CJ^JaJh%Mh"CJ^JaJh%Mh{JCJ^JaJh%Mh[CJ^JaJh%MhM;5CJ^JaJh%Mh_5CJ^JaJh%Mh[5CJ^JaJ !\skdgd d^gdc/ :3d^`3gdz :8d^`8gdu :8d<^`8gd[ :8d^`8gda 8d<^`8gd[ 8d^`8gda lsw|}  沥}oa}QAQAh%MhSa5CJ\^JaJh%MhVC5CJ\^JaJh%Mh5&+5CJ^JaJh%Mhy5CJ^JaJh%MhSa5CJ^JaJh%Mh5&+CJ^JaJh%MhaCJ^JaJh%Mh[CJ^JaJh%MhpVCJ^JaJh%Mh0JCJ^JaJh%Mh_CJ^JaJh%MhuCJ^JaJh%MhvQ#CJ^JaJh%Mh CJ^JaJ  !"/UķuhhhZLuLh%Mhr~5CJ^JaJh%MhT5CJ^JaJh%Mhr~CJ^JaJh%MhSa5CJ^JaJh%MhaCJ^JaJh%Mh+TCJ^JaJh%MhuCJ^JaJh%MhVCCJ^JaJh%Mh5&+CJ^JaJh%MhM;5CJ^JaJh%Mh5&+5CJ^JaJh%MhSa5CJ\^JaJh%MhVC5CJ\^JaJ"#(P[\̿汤旇wjZJZJZh%Mh] 5CJ\^JaJh%Mh"5CJ\^JaJh%Mh"DpOJQJ^Jh%Mh/5OJQJ\^Jh%Mhc/5OJQJ\^Jh%Mh|CJ^JaJh%MhM;CJ^JaJh%Mhr~5CJ^JaJh%Mh+TCJ^JaJh%MhaCJ^JaJh%MhVCCJ^JaJh%Mhr~CJ^JaJh%Mh_CJ^JaJ opqr~⸦zm`P@h%MhXl5CJ\^JaJh%MhaM5CJ\^JaJh%MhCJ^JaJh%Mh[TCJ^JaJh%Mh*[CJ^JaJh%Mh_CJ^JaJ"h%MhXl0J56CJ^JaJ"h%Mh_0J56CJ^JaJh%Mh^,CJ\^JaJh%Mh"CJ\^JaJh%Mh"DpCJ\^JaJh%MhaMCJ\^JaJh%Mh"Dp5CJ\^JaJ3;<= xgd:jX  !1)gdYd[$\$^gdd\$^gdadgddgda 4ǵǣp_N=N h%MhTCJOJQJ^JaJ h%Mhc/CJOJQJ^JaJ h%MhNCJOJQJ^JaJ h%MhN|CJOJQJ^JaJ h%Mh*[CJOJQJ^JaJ h%MhXlCJOJQJ^JaJ#h%MhN5CJOJQJ^JaJ#h%Mhe 5CJOJQJ^JaJ#h%Mh3):5CJOJQJ^JaJh%MhCJ^JaJh%MhNCJ^JaJh%Mh CJ^JaJ !'6CENOR]dzNjygygUgUgCgyg#h%Mh[TCJOJQJ\^JaJ#h%Mh9CJOJQJ\^JaJ#h%MhaMCJOJQJ\^JaJ#h%MhoyCJOJQJ\^JaJ&h%MhXl5CJOJQJ\^JaJ&h%MhaM5CJOJQJ\^JaJ&h%Mhc/5CJOJQJ\^JaJ&h%Mh*[5CJOJQJ\^JaJ&h%Mh5CJOJQJ\^JaJ h%MhCJOJQJ^JaJ',-01245:;µ}pcVIhYhS%CJmH sH h%MhS%CJmH sH h%Mh*}CJmH sH h%Mhc/CJmH sH h%Mh_CJaJmH sH h%Mh6CJaJmH sH h%Mh6CJmH sH h%Mh_CJmH sH h%MhH.CJmH sH h%MhH.CJh%Mh_CJhYhH.CJ hH.CJh*B*CJOJQJ^JaJmH phsH h"Kyh:jXB*CJaJph&jh"Kyh:jXB*CJUaJph(h:jXh:jXCJOJQJ^JaJmH sH (h:jXh1BCJOJQJ^JaJmH sH h1Bh1B>*B*CJaJphU$h1Bh1B>*B*CJ^JaJph-jh1Bh1B>*B*CJU^JaJph!h1Bh1BB*CJ^JaJph!h:jXh dB*CJ^JaJphh*B*CJOJQJU^JaJmH phsH 9 0&P1h:p:jX/ =!`"`#$@% $$If!vh#v#v# #v4 :V l0)655# 54 4ytyp$$If!vh#v#v4 :V l0)6554 4ytyp$$If!vh#v#v4 :V lU0)6554 4ytyp$$If!vh#v):V l4E0)65)4f4ytkP$$If!vh#v):V l40)65)4f4ytkPtDeCheck1tDeCheck1tDeCheck1tDeCheck1$$If!vh#v):V l4u0)65)4f4yt= ;$$If!vh#v):V l40)65)/ 4f4ytyp:$$If!vh#v#v#vv#v#v:V l4D0)6+++,,555v55/ / / /  / / / 4f4yt1Q4$$If!vh#v#v#vv#v#v:V l40)6+++,555v55/ / / / /  /  / 4f4yt1Q4$$If!vh#v#v#vv#v#v:V l4:0)6+++,555v55/ / / / /  /  / 4f4yt1Q4$$If!vh#v#v#vv#v#v:V l40)6+++,555v55/ / / / /  /  / 4f4yt1Q4$$If!vh#v#v#vv#v#v:V l40)6+++,555v55/ / / / /  /  / 4f4yt1Q4$$If!vh#v#v#vv#v#v:V l40)6+++,555v55/ / / / /  /  / 4f4yt1Q4$$If!vh#v#v#vv#v#v:V l40)6+++,555v55/ / / / /  /  / 4f4yt1QB$$If!vh#v#v#vv#v#v:V l40)6+++,555v55/ / / /  / /  / / 4f4yt$$If!vh#v):V l40)65)/ /  4f4yt|3$$If!vh#v#vc #v#v8:V l4 0)655c 558/  /  4f4ytljF$w00h02 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@6666_HmH nH sH tH H`H Normal CJOJQJ_HaJmH sH tH D@D  Heading 1$$@&a$ 5CJ\DA`D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 4@4 !0Header  !4 4 Footer  !^C@^ Body Text Indent $ L^`La$CJH"H Kv Balloon TextCJOJQJ^JaJ^2^ U bodytextblackdd[$\$B*CJOJQJaJph.X`A. 9Emphasis6]2BR2 K Body Textx<Pb< K Body Text 2 dxXOrX  level_capletterdd[$\$^OJQJzz ]M~(Normal + 8 pt,Small Caps,Raised by 3 pt:CJEH\o ]M~<Normal + 8 pt Char,Small Caps Char,Raised by 3 pt Char Char*:CJEHOJQJ\_HaJmH sH tH <O< }`]Style1 ] CJEH\V/V }`] Style1 Char'CJEHOJQJ\_HaJmH sH tH F^F ?}(0 Normal (Web)dd[$\$^JDZ@D }`] Plain TextCJOJQJ^JaJ*W * ?}(`Strong5\4U 4 _0 Hyperlink >*phc@@ h List Paragraph ^>/> S%0 Header CharCJOJQJaJT`"T :jX No Spacing"$CJ OJPJQJ_HaJ mH sH tH Rv!1R :jX0Unresolved MentionB*ph`^\q PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VGRU1a$N% ʣꂣKЛjVkUDRKQj/dR*SxMPsʧJ5$4vq^WCʽ D{>̳`3REB=꽻Ut Qy@֐\.X7<:+& 0h @>nƭBVqu ѡ{5kP?O&Cנ Aw0kPo۵(h[5($=CVs]mY2zw`nKDC]j%KXK 'P@$I=Y%C%gx'$!V(ekڤք'Qt!x7xbJ7 o߼W_y|nʒ;Fido/_1z/L?>o_;9:33`=—S,FĔ觑@)R8elmEv|!ո/,Ә%qh|'1:`ij.̳u'k CZ^WcK0'E8S߱sˮdΙ`K}A"NșM1I/AeހQתGF@A~eh-QR9C 5 ~d"9 0exp<^!͸~J7䒜t L䈝c\)Ic8E&]Sf~@Aw?'r3Ȱ&2@7k}̬naWJ}N1XGVh`L%Z`=`VKb*X=z%"sI<&n| .qc:?7/N<Z*`]u-]e|aѸ¾|mH{m3CԚ .ÕnAr)[;-ݑ$$`:Ʊ>NVl%kv:Ns _OuCX=mO4m's߸d|0n;pt2e}:zOrgI( 'B='8\L`"Ǚ 4F+8JI$rՑVLvVxNN";fVYx-,JfV<+k>hP!aLfh:HHX WQXt,:JU{,Z BpB)sֻڙӇiE4(=U\.O. +x"aMB[F7x"ytѫиK-zz>F>75eo5C9Z%c7ܼ%6M2ˊ 9B" N "1(IzZ~>Yr]H+9pd\4n(Kg\V$=]B,lוDA=eX)Ly5ot e㈮bW3gp : j$/g*QjZTa!e9#i5*j5ö fE`514g{7vnO(^ ,j~V9;kvv"adV݊oTAn7jah+y^@ARhW.GMuO "/e5[s󿬅`Z'WfPt~f}kA'0z|>ܙ|Uw{@՘tAm'`4T֠2j ۣhvWwA9 ZNU+Awvhv36V`^PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!g theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] }} r ( h  p ^|ECl ;)a *,.01234678:;<=?@ABF Z b  d 2>JVbnz  a!"#$%&'()+-/59>CK[fvG$G$G$G$L/GX4X@ @H 0(  (  J  X?"Text Box 2S"Ð?PK!8[Content_Types].xmlAN0EH%N@%邴K@`dOdlyLhoDX3'AL:*/@X*eRp208J妾)G,R}Q)=HiҺ0BL):T뢸WQDY;d]6O&8* VCLj"󃒝 yJ.;[wIC_ :{IOA !>Ø4 p;fɑ3׶Vc.ӵn(&poPK!8! _rels/.relsj0 }qN/k؊c[F232zQLZ%R6zPT]( LJ[ۑ̱j,Z˫fLV:*f"N.]m@= 7LuP[i?T;GI4Ew=}3b9`5YCƵkρؖ9#ۄo~e?zrPK!&b%Gdrs/e2oDoc.xmlSێ }@7vIvcYmMUi{v $vp6KU sfVV `*:áfWѯO77LQѣvժ(GBey 0litqGt"YoG']'<|n[/QB]g+wNSL u#{'Ғ;І AJ.R X4QcǬH 9ޞi:|qD6-הQ'1RD~zK {FS>扁MN9}'XM#Ha hh!QY j/7EX: $*P>tXdJ%rQi ^)C.|dyZ2`++zsbeiR?&xƔ9Y C=9"IC%=vuE=s,l 5rHܥ0 itaDly+vk4Yq.k?PK!H['rdrs/downrev.xmlLAO0 HHXc*MmH\&)Mڕ9b3{'&;.BTQzAj6U g!sЦRƺ"rhL7۪acU>nݷַ7Ds??|FNa$$ ٚٽZpţR B^PK-!8[Content_Types].xmlPK-!8! /_rels/.relsPK-!&b%G.drs/e2oDoc.xmlPK-!H['rdrs/downrev.xmlPK B S  ?j z)'T _Hlt61518959 _Hlt61518960hh@@ii<=<=3#(XY^ahijl+..QR``w9Hbcef}~iijjkk%/zz *9dek{!0JKbb,CDXY\]mn  g h j k 8 9 ; < } :;;<=#(XY^ahijl+..QR``w9Hbcef}~iijjkk%/zz *9dek{!0JKbb,CDXY\]mn  g h j k 8 9 ; < } :;;<=[Z.|B"W1K.V hh^h`o(hH. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH. hh^h`o(hH. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.W1K[Z.                  Cp\!T,rdd/E2X'@I oT,rX'@ 99%y~6o!SR/A0 M8The 3 Lk5? h? ] N]  0? j  q eIz*G]7c/z?QYTcXlWxuaw9T-ddb 8 gO W!so!m""7#vQ# && &K&y&~&7 ''?}(F5)=I)/K*+5&+1+|,H.0Z0C0& 1xS1|314i 4#4Q4$Y4J6N78$:3):= ;M;c; =/=?H?(@8B1BVC+EljFqGHG4SI)9J{J%M#MPMaMNpNNkPmmPQQUQ[Rr$SNESsST;T+TD+UpV?W:jXY*[l1[\]\]}`]f_u_S aSae]aVb*c0c dZdB`gyg"hShoi;pitiH"j4ZjplkT+lObl$nto"DpMpypS|pNq&nsG=t"Kyoyn#zczD{8|N|*}u}]M~I0JSo+96?"Vs"^,`|}7/T mo Cm7E<E} "mgm\ToN_i$ b@~U#4)ab (^ S%d *5;dC1QahoUFplYMhGFYz<g[^bU1J==KvX[&qO6&Oez gY7p4x&\ogDPT"e_dDe?agr~"J\@L[  @@Unknown G.[x Times New Roman5Symbol3. .[x ArialO=  jMS MinchoMS Mincho5. .[`)Tahoma7. [ @Verdana?= .Cx Courier NewC.,*{$ Calibri Light7.*{$ CalibriA$BCambria Math"hYgsX ! !`924 3qHX ?J2! xx ? AMedical Statement Form - USDA Civil Rights (CA Dept of Education)zThis form is used by parents/guardians to have a medical authority prescribe special meals or accommodations during meals. Lori PorterChristopher Slaven  Oh+'04h|     $,DMedical Statement Form - USDA Civil Rights (CA Dept of Education)|This form is used by parents/guardians to have a medical authority prescribe special meals or accommodations during meals. Lori Porter Normal.dotmChristopher Slaven8Microsoft Office Word@@`J@7@z] ՜.+,D՜.+,p px   RTracey Smith,CA Dept of Education, Nutrition Services!  BMedical Statement Form - USDA Civil Rights (CA Dept of Education) Title 8@ _PID_HLINKSA *Wmailto:program.intake@usda.govYrhttps://www.usda.gov/sites/default/files/documents/USDA-OASCR P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGIJKLMNOPRSTUVWXYZ[\]^_`abcdefghijklmnopqrtuvwxyz|}~Root Entry F`@Data H1TableQBWordDocument ;SummaryInformation(sDocumentSummaryInformation8{MsoDataStore0zCK5QDGGENN1ZR==20zItem  2PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q