Template Special Milk ProgramParticipation Record

Use this form to record the number of half-pints (8 fl. oz or ½ pint equivalent) of milk served to students participating in Special Milk Program (SMP) on the corresponding day. This form must be completed at the time of milk service, when each child receives their milk, also known as the Point of Service (POS). Note, milk served to adults cannot be claimed for reimbursement.

  • Pricing with Free Milk Option Program: This template is not allowable for this program model as consumption must be tracked by individual student.
  • Pricing Program (no free milk): This template may be used for this program model unless the SFA charges individual students by ½ pint (8 fl. oz) consumption.
  • Nonpricing Program: This template may be used for this program model.

Month: / School/Classroom:
Day of Month: / Date of Month: / Date of Month: / Date of Month: / Date of Month:
Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk
Day of Month: / Day of Month: / Day of Month: / Day of Month: / Day of Month:
Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk
Day of Month: / Day of Month: / Day of Month: / Day of Month: / Day of Month:
Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk
Day of Month: / Day of Month: / Day of Month: / Day of Month: / Day of Month:
Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk
Day of Month: / Day of Month: / Day of Month: / Day of Month: / Day of Month:
Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk / Student Milk / Adult Milk

Total Number of Half-Pints (8 fl oz.) Distributed to Students: ______ Total Number of Half Pints Distributed to Adults: ______

Keep this completed record on file for three years plus the current school year.