Programs & Services - Fuel Up! School Lunch Program - Subsidy - Subsidy Application Form

Programs & Services - Fuel Up! School Lunch Program - Subsidy - Subsidy Application Form

Fieldset

Student Information

Legal last name: *

Legal first name: *

School: *

Grade *

Division *

Additional Student(s) Information

Child 2, Legal last name:

Legal first name:

School:

Grade

Division

Child 3, Legal last name:

Legal first name:

School:

Grade

Division

Child 4, Legal last name:

Legal first name:

School:

Grade

Division

Parent Information

Parent/legal guardian (lives with student): *

Contact Email: *Please give the email address that the Fuel Up Coordinator should contact to confirm arrangements.

Telephone: *

Subsidy Information

I am seeking a lunch subsidy for:

To help us understand the needs families are facing, or to anticipate what that looks like over time, we'd appreciate if you can take a moment to share this information with us. If you don't feel comfortable, we understand and you can skip this question.Financial Reasons (see below)A special circumstance (see below)

Please briefly describe your reasons for applying for the Fuel Up! subsidy:

To assist in providing as many healthy meals as possible, please pay what you can. Some families will require a full subsidy, where meals will be provided at no cost to the families, and some families will be able to pay a partial fee with a partial subsidy. Do you require a partial subsidy or a full subsidy?

Subsidy Level: *

I require a PARTIAL subsidyI require a FULL subsidy

If you are seeking a partial subsidy, please select the amount that YOU are able to pay:

Duration - I expect that I will need this subsidy until (approximate date): *

Agreement

I have read and understand: *

the program informationevery effort will be made to provide allergen free meals, however, common food allergens are used in our caterer's kitchen and cross contamination is always a possibility.that if my child(ren) has severe allergies, I should pack a meal from home instead of using the school lunch program.

Verification

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