Application for Summer Food Service Program

Summer Food Service Program (SFSP)

Tuesday, June 14, 2016 - Friday, August 26, 2016

Please complete your application by Friday, April 15th to be part of the Summer Food Service Program.

By completing and submitting this application, you understand and agree to:

MEAL REQUIREMENTS AND MEAL SERVICE

  • Children 18 years of age or younger or
  • Individuals 19 and over with a state defined mental or physical disability are eligible to receive meals.
  • Comply with civil laws and regulations in accordance with USDA policy which does not permit discrimination because of race, color, age, sex, handicap or national origin.

As a supervisor or staff member of a site, you will in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)

Nondiscrimination Statement - Read in Hmong, Karen, Somali, and Spanish: 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, religious creed, disability, age, political beliefs, 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 the USDA Program Discrimination Complaint Form, (AD-3027) found online at http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the informaiton requested in the form.  To request a copy of the complaint form, call (866)632-9992.  Submit your completed form or letter 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;

(2)     fax:  (202) 690-7442; or

(3)     email: program.intake@usda.gov.

This institution is an equal opportunity provider.

Site Name 
(Example: "Parks & Rec", Independent, Library, etc.)
Organization Running Program 
Name of Site Contact Person 
Name of Person(s) Responsible for Meal Service 
Telephone Number ( )___-____  
Additional Telephone Number 
Address 
City 
State 
Zip 
Email 
What are the hours of operation? 
Will you be picking up your meals or want delivery?





(*where the refrigerator will be - ex. East door off "street" on..., ground floor at end of front hallway)
*If meals delivered, location in building for delivery of meals 
(gym, hallway, room 212, etc.)
Location where meals are served 
Did this site participate in 2015 SPPS SFSP?

If yes, how many average meals per day did you serve during summer 2015? 
What is the total number of meals expected to serve per day for summer 2016? 
If number expected 2016 is greater 10% of 2015 served, explain why it'll be higher. 
Maximum number of people allowed in your building at the same time 
Is this site a non-profit organization


Select only one
You agree your summer meals will be open for all children not just children enrolled?

If your summer program is not available to all children, SPPS may not accept your application to be part of the SPPS Summer Food Service Program.