Food/Account Restriction Request by HUNwIU


									                                                                                  Food & Nutrition Services
                                                                                 Traci Miller, RD LD Director

                                                    &       Cavalier Café
                                   Student Snack Permission Form
The Food & Nutrition Services department operates a computerized student account system through which
lunches may be purchased. If you would like to place a restriction on your student’s meal or snack purchases,
fill out the form below.
         Failure to submit this form assumes no snack or meal purchase restrictions.
Student Name: (Type name)     Student ID#: (Type ID#)
Grade:        (Type grade)
Meal and Snack Purchasing Restriction Options
A meal consists of 3 to 5 components with at least one being a fruit or vegetable. Components are: fruit,
vegetable, grain, meat/meat alternate, and milk. Up to 5 components may be selected and still be considered
a single meal.
If additional items are selected by your student (i.e. a second entrée, water, extra roll, etc.) these items are
considered à la carte. All à la carte items are charged individually at the posted prices.
 Snacks available for K - 8th grade will include, but are not limited to items such as:
 Nutrigrain bars, granola bars, Goldfish crackers, fruit parfaits, yogurt, reduced- fat string cheese, beef
 jerky, pretzels, baked chips and reduced sugar cookies or muffins.
 Elementary schools sell small ice cream treats 1-2 times/week (depending upon the campus).
To select meal/snack purchasing restrictions for your student’s lunch account, please “X” ONE of the following:
         I authorize my student to purchase “snack/à la carte one day only”
                Select which day:          Mon           Tue        Wed         Thurs       Fri
         I authorize my student to purchase “snacks/à la carte with cash only”
         I authorize my student to purchase a “Meal + extra entrée/ fluid only”
        *I authorize my Middle School student to purchase a “Meal or chick-fil-a only”
                 (*for MS students where/when available)
        *I authorize my High School student to purchase a “Meal or chick-fil-a/pizza only”
                 (*for HS students where/when available)
        I authorize my student to purchase “Full meals only - NO à la carte”
                     (a minimum of 3 of the 5 components are required per “full” meal)
I understand these restrictions will remain in place unless I request cancellation or modification in writing to the
Café. Please allow one week for processing. If you have questions about this form, please contact your
Café Manager or Food & Nutrition Services office at 512-533-6035 or by e-mail to
If your child has food allergies, please request additional form/information to
** All dietary restriction requests must be accompanied by a doctor’s statement.

Parent/Guardian:(Typing name here indicates acceptance by parent/guardian)                    Date:(Date)

Once Completed, this form must be e-mailed or printed and delivered to the Café Manager at the
campus your student attends in order to be processed. Please deliver as follows:
             LTE –            LWE –
             BCE –            LPE –
             SHE –              LTMS –
             HBMS –            LTHS –

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