SUMMER FOOD SERVICE PROGRAM (SFSP) 2013 APLICATION
1.GENERAL INFORMATION
A. Site Name: ______
B. Site Address where meals will be stored and served:
______
Did this site previously participate in the SFSP?Yes: ______No: ______
Did this site participate in the CACFP? Yes: ______No: ______
C. Is this site located in a public school building?Yes: ______No: ______
If YES, what is the name and/or number of the school? ______
If NO, what is the closest school to your site? ______
D. Site Contact Information
Site Supervisor Name: ______DOB:______
E-Mail Address: ______
Site phone #: ______Cell phone #: ______
E. With which of the following agencies do you most closely associate? Please check only one.
Public School: ______Private School: ______Faith-Based: ______
Recreational Center: ______Facility for the Disabled: ______Super Kids: ______
Licensed Child Care: ______City Agency: ______Community-Based: ______
Other ______
F. What type of enrichment activities does your program offer? ______
______
2. RACIAL/ETHNIC DATA: Please make anumerical estimate for your upcoming program.
A. Racial Identities: American Indian/Alaskan Native____ Asian ____Black/African American____
Native Hawaiian/Pacific Islander: ____ White____
B. Ethnic Identities: Hispanic____ Non Hispanic or Latino ____
3.SITE MEAL ORDERING
A. Site start date: ______Site end date: ______
B. Check the days of the week supper will be served.
Mon. _____Tues. _____Wed. _____Thurs. _____Fri. _____
E. Estimate the Number of days your site will be serving suppers for each month.
June____ July_____ August _____
F. Estimate the total number of children that you plan to serve daily.
Total Number for Supper: ______
G. Please choose a meal serving time between 3:00-7:00pm
Supper time: ______
Special delivery instructions: ______
4. Do you have adequate means to dispose of trash? YES______NO______
5. Do you have daily access to a computer with internet? YES______NO______
6. Does your site have a refrigerator large enough to store your children’s milk? YES_____NO______
7. Will your site accept walk-ins? (Note: If you wish to serve more children by accepting walk-ins FLBC will work closely with you to support staff at your site) YES_____NO______
I certify that the information on this form and subsequent attachments is true to the best of my knowledge. I understand that this information being given in connection with the receipt of federal funds and that deliberate misrepresentation may subject me to prosecution under applicable state and criminal statutes. I also agree to make my program available to all children regardless of sex, age, disability, color, religion, or national origin.
Signature of Site Representative: ______Date: ______
Training for the Supper Program is required. You will be contacted when Trainings are scheduled.
Please return this application to Melissa Moore at The Family League of Baltimore City via email or fax 4106625520. For more information contact Melissa at 410-662-5500 ext. 272.
***This is a separate program then the breakfast and lunch program. You can receive all three meals but must apply separately to both programs. For more information about Breakfast and Lunch contact Baltimore Housing at
FLBC STAFF USE ONLY
Approved MARS #______Attended Training______Date______Updated Meal Count______