Transcription of Medical Statement / Parent Preference Chart
1 Cape Fear TutoringMedical Statement / Parent Preference Chart07/2013Is it an Allergy?Is it a Parent 's Preference ?Use Medical Statement FormUse CFT Parent 's Preference Form Milk & Non MilkMilkNon MilkDisabilityMed. Conditionlactose freeSoyFacility Name Facility Name No Form NeededFacility Name Facility Name Child's NameChild's NameChild's NameChild's NameDOBDOBR eason to omit MilkFood's to omit#3, #5, #6#4, #5, #8, #9 Provided by CheckedProvided by checked#7, #8, #9#13(by doctor) orParent's SignatureParent's Signature#13(by doctor only)#14(by Medical Authority)Facility SignatureFacility SignatureDateDateDateDate#1#2#3#4 Any center who is a Peanut Free Zone or any other Free Zone needs to send us a notice for our records. Include Center Name and signature of director Special Diet Issues
