ACRFB Membership Application

Contact Information
Agency Name:
Hot Meal Name (if different than agency name):
Main Contact: / Title: / Is this position:
☐ Volunteer ☐ Paid Staff
Email: / Is there daily access to email? / ☐ Yes ☐ No
Primary Phone: / ☐ Cell / ☐ Work / ☐ Home / ☐ Program Site
Alternate Phone: / ☐ Cell / ☐ Work / ☐ Home / ☐ Program Site
Preferred Contact Method: / ☐ Phone / ☐ Email
Address of Meal Site:
City: / Zip Code: / County:
If the Meal Site has a separate phone number, please provide:
Address of Food Storage Site (if different from meal site):
City: / Zip Code: / County:
If the Food Storage Site has a separate phone number, please provide:
Additional Contact #1
1. Name: / Title: / Is this position:
☐ Volunteer ☐ Paid Staff
Email: / Allowed to order? / ☐ Yes ☐ No
Allowed to pick-up? * pick-up contacts must provide a cell phone number / ☐ Yes ☐ No
Phone: / ☐ Cell / ☐ Work / ☐ Home / ☐ Program Site
Additional Contact #2
2. Name: / Title: / Is this position:
☐ Volunteer ☐ Paid Staff
Email: / Allowed to order? / ☐ Yes ☐ No
Allowed to pick-up? * pick-up contacts must provide a cell phone number / ☐ Yes ☐ No
Phone: / ☐ Cell / ☐ Work / ☐ Home / ☐ Program Site

* To include additional contacts on the account, please attach a separate sheet with the information listed above for each individual.

Hot Meal Program Billing Information and Budget
Billing Contact: / Title:
Billing Phone: / Billing Email:
Billing Address:
City: / Zip Code:
Do you charge any fees for the food provided through the hot meal program? / ☐ Yes / ☐ No
Do you request a donation from participants of the hot meal program? / ☐ Yes / ☐ No
Monthly food budget for the program: $
Hot Meal ProgramCapacity
Date the hot meal program began (Month & Year):
Please check all the equipment and storage items available to the food program:
☐ Residential Fridge / ☐ Residential Freezer / ☐ Shelving / ☐ Computer / ☐ Printer
☐ Commercial Fridge / ☐ Commercial Freezer / ☐ Carts / ☐ Internet Access / ☐ Copier
☐ Food Warming Equipment / ☐ Food Grade Thermometer / ☐ Stove / ☐ Dishwasher
Is the site where clients are served handicap accessible? / ☐ Yes / ☐ No
Has staff or volunteers with the program participated in food safety training? / ☐ Yes / ☐ No
Is there a food service license held by the site where food is prepared? / ☐ Yes / ☐ No
Is the food prepared at the same site where it is served? / ☐ Yes / ☐ No
If no, where is the food prepared and how is it transported to the meal site?
Do you deliver meals as part of the hot meal program? / ☐ Yes / ☐ No
If yes, please explain the delivery process and include how delivery eligibility is determined, how the food is transported and who transports the food:
Hot Meal Program Service Plan
Days and hours of hot mealoperation (check all that apply):
☐ / Monday / Hours: / Week of the month / ☐ 1 ☐ 2 ☐ 3 ☐ 4
☐ / Tuesday / Hours: / Week of the month / ☐ 1 ☐ 2 ☐ 3 ☐ 4
☐ / Wednesday / Hours: / Week of the month / ☐ 1 ☐ 2 ☐ 3 ☐ 4
☐ / Thursday / Hours: / Week of the month / ☐ 1 ☐ 2 ☐ 3 ☐ 4
☐ / Friday / Hours: / Week of the month / ☐ 1 ☐ 2 ☐ 3 ☐ 4
☐ / Saturday / Hours: / Week of the month / ☐ 1 ☐ 2 ☐ 3 ☐ 4
☐ / Sunday / Hours: / Week of the month / ☐ 1 ☐ 2 ☐ 3 ☐ 4
☐ / On-call for emergency situations
Average number served each month: / # of people: / # of meals:
How often may the same person receive food?
What percentage of each age group do you serve? / % Under 18 / % 18-64 / % 65+
Do you limit the clients you serve by age, income level, gender or other reason? / ☐ Yes / ☐ No
If yes, please explain:
Describe your geographic service area (zip code, township, city, etc.):
How does your organization determine eligibility for the hot meal program?
Describe the process and attach sample forms if applicable.
Please describe how the hot meal program is advertised to the public:
Does your organization require client income verification for food or other assistance? / ☐ Yes / ☐ No
If yes, please explain the requirements and purpose:
Does your organization require photo identification for food or other assistance? / ☐ Yes / ☐ No
If yes, please explain the requirements and purpose:
Does your organization provide any programming prior to, during, or immediately following the time when the hot meal is served? (examples:religious service, bible study, education program, clothing distribution) / ☐ Yes / ☐ No
If yes, please describe the type of program, activities and time:
Are hot meal clients required to participate in the program in order to receive food? / ☐ Yes / ☐ No
Does your organization require a referral to receive food? / ☐ Yes / ☐ No
If yes, who provides the referrals? Please explain the referral process:
Please describe record-keeping system for the hot meal program. Items may include how you track clients served, number of meals served, food inventory, equipment maintenance/needs.

Revised October 2011Section 51|Page