Bethlehem Central School District Food Service
Account Restriction Form
The BCSD Food Service Department operates a computerized student account system through which student
meals and a la carte or snack items may be purchased. If you would like restrictions placed on your child’s
account, or if your child has any special dietary restriction (not allergy-related), please utilize this form to
describe your particular needs to the Food Services Department. Please return this form to your school
cafeteria manager.
Student’s Name:
Account Number:
Grade/School:
IMPORTANT! This form is not to be used for Food Allergy notifications. Those notifications should be shared with
the school nurse who will contact the Food Service Department. If you have any questions regarding this form or
restrictions, please contact Food Service Director Paul Franchini at (518) 439-7481 ext. 22118 or by email at
[email protected].
Please use the following chart and circle the restrictions or choices that apply. Please complete a separate form for
each student. While we will do our best to honor these restrictions, our account management system will currently
show only TWO restrictions for each student.
2nd ENTREE
No 2 nd entrée
allowed
Yes, allowed 2 nd
entrée on Pizza
Day only
Yes, allowed to
purchase 2 nd
entree
SNACKS
No snacks allowed
Snacks one day a
week:
M Tu W Th F
Snacks two days a
week:
M Tu W Th F
ICE CREAM
No ice cream
allowed
Ice cream one day
a week:
M Tu W Th F
Ice cream two days
a week:
M Tu W Th F
MILK
No Chocolate Milk
CHARGE
PRIVILEGES
No charging
anything
White milk only
CASH only for
meals
Soy milk – $0.75
with meal
CASH only for
snacks
Water - $1.00
Juice Cup – $0.35
ADDITIONAL RESTRICTIONS:
PLEASE NOTE:
•
•
•
A doctor’s note is required to be able to give your child juice in place of milk with a meal. The note should be
sent to the Nurse’s Office in your building.
Notes carry over from one year to the next and can only be removed by the parent contacting the Food
Service Director.
Allergy information also carries over from year to year. If changes are needed, a note needs to be sent to
the Nurse’s Office in your building.
You can always review your child’s account activity at MySchoolBucks.com. If you find activity on your child’s
account that does not match requested restrictions, contact the Food Service office at 439-7481.
Parent Signature
Date:
Phone number: