Food Allergy Forms & Information

CAP has established guidelines to accommodate children with both mild to severe food and milk allergies.  A severe allergy is defined as an allergy that would pose a life threatening danger without immediate medical assistance.  All staff exercise reasonable care to ensure that no child is exposed to an allergen for which a child’s parents/guardians have provided notice.  Due to rising food allergies specifically related to nuts, CAP operates a peanut, tree nut, and seafood free program.  It is imperative to remember that products containing any nuts or peanut products are not permitted in the CAP space.  For some children with severe food allergies or nutritional requirements, it may be necessary for parents to provide their child’s snack while attending the CAP program.  Both CAP and the USDA have mandatory forms required for children with all types of food and milk allergies. 

 

If you are the parent of a child with food allergies either mild or severe, please select from the table below those forms associated with your child’s food allergy.  These forms are MANDATORY and must be completed and on file with the CAP office before your child’s first day at CAP.  If you have any questions about these forms, please do not hesitate to call the CAP office at 541-967-9322.

 

GAPS, the USDA, and the Oregon Department of Education Child Nutrition Programs have recently modified meal accommodations for participants with disabilities.  A disability is defined as a major life activity or major bodily function that is affected by the participant’s physical or mental impairment which restricts the diet.  Please see the “Medical Decision Tree” for assistance in determining if your child qualifies for food and/or milk substitution.

 

Medical Decision Tree

 

FOOD ALLERGY REQUIRED MEDICAL FORMS & POLICIES

Allergy Required Forms
Fluid Milk CAP Milk Substitute Request Form
Severe Fluid Milk* USDA/ODE Medical Statement – Special Meals and/or Accommodations
CAP Severe Allergy Medication Policy
CAP Participant Health Form
CAP Release Waiver for Severe Allergies
Dairy USDA/ODE Medical Statement – Special Meals and/or Accommodations
Severe Dairy* USDA/ODE Medical Statement – Special Meals and/or Accommodations
AND
CAP Severe Allergy Medication Policy
CAP Participant Health Form
CAP Release Waiver for Severe Allergies
Food (Eggs, Soybean, Wheat, etc.)* USDA/ODE Medical Statement – Special Meals and/or Accommodations
CAP Food Substitute Request Form (Snack Program Sites only)
Peanut/Tree Nuts*
(Mild & Severe)
USDA/ODE Medical Statement – Special Meals and/or Accommodations
AND
CAP Severe Allergy Medication Policy
CAP Participant Health Form
CAP Release Waiver for Severe Allergies
Fish, Shellfish*
(Mild & Severe)
USDA/ODE Medical Statement – Special Meals and/or Accommodations
AND
CAP Severe Allergy Medication Policy
CAP Participant Health Form
CAP Release Waiver for Severe Allergies

*If CAP and/or GAPS is unable to accommodate your child’s particular food allergy/nutrition requirements, please complete the “Food Allergy/Nutrition Program Release/Waiver” below.  It will be your responsibility to provide your child’s snack (and/or lunch during the Summer CAP program) when he/she attends the CAP program.

 

CAP Food Allergy/Nutrition Program Release/Waiver

 

 

 

 

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

  1. mail:
    U.S. Department of Agriculture
    Office of the Assistant Secretary for Civil Rights
    1400 Independence Avenue, SW
    Washington, D.C. 20250-9410; or
  2. fax:
    (833) 256-1665 or (202) 690-7442; or
  3. email:
    Program.Intake@usda.gov

“The Community After-School Program is an equal opportunity provider.”