2025 Home Delivery Brown County Question Title * 1. In order to provide home delivered meals, we need your consent.All information disclosed in this form will be kept confidential in accordance with confidentiality and disclosure provisions in the National School Lunch Act and SFSP regulations (7 CFR 225.15(f)-(l).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, disability, age, 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 information 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. Please Provide: Last Name * First Name * Address * Apt./Lot#? City/Town * ZIP/Postal Code * Email Address * Phone Number * Question Title * 2. Do you live in Brown County, Ohio? yes no Question Title * 3. What local public school district is your physical home located in? (If your child would attend the public school - even if home schooled, which district would they attend?) Ripley Union Huntington Lewis Fayetteville/Perry Eastern Brown Western Brown Georgetown NONE OF THE ABOVE-type in school district: Question Title * 4. How many children do you need weekly boxes for? 1 2 3 4 5 6 7 8 Question Title * 5. Are there any allergies UMCFOOD needs to be aware of? If so, list the child and the allergies. NO YES. Please Explain (include child's name) Question Title * 6. To help us with routing, do you know your children's BUS ROUTE NUMBER for your School? Question Title * 7. What is the name of your regular school bus driver? Question Title * 8. Please provide any dates that you will be on VACATION or out of town, when deliveries should be stopped (E.g. July 2-9) Question Title * 9. UMCFOOD is providing you weekly meals all summer. The weekly meals will include breakfast and lunch. Do you agree that:a) Food is only for children in your household 18 and underb) You will not receive from any other sponsor (or school) meals in the Summer Food Service Program, as your children have received the maximum number of meals through home delivery? Yes No Question Title * 10. By typing my full name below, I understand that household contact information may be shared with school staff, volunteer deliverers and staff of UMCFOOD. I also give consent for meals to be left at doorstep if no one is home at the time of delivery or responds to the delivery. I understand it is my responsibility to ensure the proper safety and protection of meals if no one is home. IF I CHECKED FROZEN MEALS, I understand it is imperative that I'm on the lookout on my assigned delivery date for when the meals are delivered to store them safely.PLEASE TYPE YOUR FULL NAME HERE Question Title * 11. Any comments for UMCFOOD to help us provide you with great service this summer? (e.g. delivery suggestions) Question Title * 12. Do you prefer shelf stable meal boxes, or boxes with frozen microwaveable meals? Frozen All shelf Stable Either Question Title * 13. Child 1 Information Last Name First Name Grade Age School student attends (if any). If none, say n/a Question Title * 14. Child 1 Ethnicity: Prefer Not to answer Hispanic-Latino Non-Hispanic Question Title * 15. Child Number 1 Race Prefer Not to Answer American Indian or Alaskan Native Asian Black or African American Native Hawaiian White Question Title * 16. Do you have additional children to enter? Yes No Next
