Family League of Baltimore



Child and Adult Care Food Program (CACFP): After-school Meals Program ApplicationSY 2019 – 2020Please complete this application to participate in Family League of Baltimore’s After-school Meals Program, which runs from the first through last day of Baltimore City Public Schools (BCPS). Please complete all fields, sign where required, and submit to the Food Access Team via email to food@ or fax to 410-497-6647. Please note that only complete applications (including supplementary documents) will be accepted for review and failure to submit a complete application may result in a delay in meal service.GENERAL PROGRAM INFORMATIONProgram Name: _______________________________________Name of Nearest School: ________________________________Program Address (i.e., meal service site): ___________________________________________Which of the following most closely describes your organization? Please check only one.Private school_____ Rec Center_____ City Agency_____ Community-based Org_____Child Care Ctr_____ Faith-based Org_____ Facility for the Disabled_____Other (please specify) ________________________________________________________What educational/enrichment activities are offered through your program (e.g, homework help, tutoring, performing arts, athletics, etc.)? ____________________________________________________________________________________________________________________________________PROGRAM STAFF CONTACT INFORMATION (please note, we require at least two contacts)Site Supervisor’s Name: ____________________________________ DOB: ___________Site Supervisor’s Email: ____________________________________ Office Line: _______________Supervisor’s Cell Number: _________________________ Accepts Texts? _______Secondary Contact’s Name: ____________________________________ DOB: ___________Secondary Contact’s Email: ________________________________ Office Line: ________________Secondary Contact’s Cell Number: _________________________ Accepts Texts? _______Exec. Director’s Name: ____________________________________ DOB: ___________Exec. Director’s Email: ________________________________ Office Line: ________________Exec. Director’s Cell Number: _________________________ Accepts Texts? _______REQUESTED MEAL SERVICEMeals Start Date: _________ Meals End Date: _________ Hours of Operation: ______________Does your program operate when schools are closed for heat? ______ For snow? ______Check the days of the week SNACK will be served:Mon_____ Tues_____ Wed_____ Thurs_____ Fri_____ Sat_____ Sun_____Snack Time: ________ How many SNACKS will be served each day? ______Check the days of the week SUPPER will be served:Mon_____ Tues_____ Wed_____ Thurs_____ Fri_____ Sat_____ Sun_____Supper Time: ________ How many SUPPERS will be served each day? ______Special Delivery Instructions: ___________________________________________________________If you are receiving ONLY snack, you must be able to accept and store several days’ worth of snacks. Delivery may be limited to twice weekly. Can your program accommodate this? _________If you are receiving BOTH snack and supper, you must and store snack for the following day. Can your program accommodate this? _______Does your site have a refrigerator large enough to store your participants’ milk? ______Family League’s policy is to cancel meal deliveries when Baltimore City Public Schools (BCPS) are closed or dismissed early. Please carefully review the list of BCPS closures and early dismissals and indicate which dates you intend to serve meals. You will only receive meals if you indicate your intent to serve below. Meal Service on BCPS Professional Development Days and Federal HolidaysDo you need meals on BCPS Professional Development (PD) Days and/or Federal Holidays (check all that apply)?10/17 (Th)____ 10/18(F)____ 11/4(M)____ 1/20(M)____ 1/24(F)____ 2/17(M)____ 3/13(F)_____ 4/28(Tu)____ 5/25(M)____ 6/16(T)____ Meal Service on BCPS Holidays and BreaksDo you need meals the week of Thanksgiving (check all that apply)?11/25(M)_____ 11/26(Tu)_____ 11/27(W)_____ 11/28(Th)_____ 11/29(F)_____Do you need meals during Winter Break (check all that apply)?12/23(M)____ 12/24(Tu)____ 12/25(W)____ 12/26(Th)____ 12/27(F)____ 12/30(M)____ 12/31(Tu)____ 1/1(W)____Do you need meals during Spring Break (check all that apply)?4/6(M)_____ 4/7(Tu)_____ 4/8(W)_____ 4/9(Th)_____ 4/10(F)_____ 4/13(M)_____Meal Service on BCPS Early Release DaysDo you need meals on BCPS Early Release days (check all that apply)?10/2(W)____ 12/4(W)_____ 1/8(W)____ 2/5(W)____ 3/4(W)____ 4/1(W)____ 5/6(W)____PERMITSIn order to participate in the program, you must have and submit with this application copies of valid Fire (Snack and Supper) and Health (Supper only) Permits.Do you have a valid Fire Permit? ______Fire Permit Expiration Date: _______Do you have a valid Health Permit? _______ Health Permit Expiration Date: ______RACIAL/ETHNIC DATAPlease make a numerical estimate (e.g., 6) for your upcoming program. Racial Identities: Black/African American _______ Asian _______ Caucasian (White) _______American Indian/Alaskan Native _______ Multi-Racial _______ Latin _______Native Hawaiian/Other Pacific Islander ________ Other _______How did you hear about us (please check all that apply)?Partner: ______Community Advocate: ______Media ______Faith-Based Institution: ______Recreational Center: ______Lic. Child Care: ______City Agency: _______Child Participant: ______Comm-Based Org: ____Family League Social Media: _______ Other (please specify): ________________________Site/Program Sponsor Agreement________________________________________ (Site/Program name) agrees to the following:Attend annual training conducted by Family League of Baltimore’s (hereafter FL) Food Access Team;Comply with Civil Rights laws and regulations (e.g., make my program available to all children/youth regardless of sex, age, disability, color, religion, and/or national origin);Serve meals to eligible children aged 18 years and under;Serve meals that meet minimum CACFP meal pattern requirements;Provide adequate supervision during meal service;Responsibly dispose of waste and recycle when available;Report to FL any closings, food cancellations, and/or other issues regarding meal service;Report to FL any changes required to number of meals received as a result of fluctuations in attendance;Maintain accurate and complete records for all meals served including, but not limited to, attendance counts, meal counts, and vendor invoices;Update online attendance and meal count data daily;Submit to FL hardcopy point-of-service (i.e., meal counts) by the FIFTH of each month;Acknowledge that the site is financially obligated to reimburse FL for the cost of meals that are disallowed for the following reasons:Required reports, data, or records are not completed and/or maintained properly;Meal changes and/or cancellations are not reported timely; and/orMeals are not served according to the minimum meal pattern requirements.Acknowledge that meal service may be temporarily suspended and/or terminated for repeated non-compliance and/or non-payment of invoices for meals lost as a result of such non-compliance;Notify Family League of Baltimore immediately of any staffing/contact information changes;To read and abide by all program guidelines as specified in Family League’s After-School Meal Program Policies and Procedures Manual.In addition to these requirements, as an authorized representative of _______________________________, I certify the following:The information on this form and subsequent attachments is true and accurate to the best of my knowledge. I understand that this information being given is in connection with the receipt of federal funds and that deliberate misrepresentation of any kind may subject me to prosecution under applicable state and criminal statutes. Authorized Site Representative’s Signature: _________________________________________Date________Family League Staff’s Signature: __________________________________________________ Date _______ ................
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