School/Agency Information

School or Agency

Name of Principal or Director

School/Agency Address

Address 2

City/Town

State

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP

Parish

Site Coordinator Information

Name

Email Address

Phone Number

Program Information

How many of your students would you estimate are chronically hungry?

What percentage of your students participate in the Free/Reduced Price Lunch Program?

Hours of Operation

Ages of Students Served

Facility Information

Yes

No

Is there a location available to store boxes from delivery until distribution?

Yes

No

Can food be stored at least six inches off the floor?

Yes

No

Is the area secure?

Yes

No

Is there a loading dock, or other location to receive deliveries?

Yes

No

I CERTIFY THAT THIS INFORMATION IS TRUE AND COMPLETE

Name

Title/Position