Please complete the Summer Food Service Program Eligibility Form for Camps and Enrolled Sites using the instructions below. Sign the application and return it to the sponsoring organization. Call the Sponsor if you need help at (574) 232-8523.
PART 1 – PARTICIPANT’S INFORMATION: ALL HOUSEHOLDS COMPLETE THIS PART.
(1) Print the name of your child that is registering for camp.
PART 2A – HOUSEHLDS GETTING FOOD STAMPS OR FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR) OR TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF) BENEFITS: COMPLETE THIS PART and PART 3.
(1) List your current food stamp case number or your FDPIR or TANF identification number for the participant.
(2) An adult household member must sign & complete the statement in PART 3.
PART 2B - ALL OTHER HOUSEHOLDS: COMPLETE THIS PART and PART 3.
(1) Write the names of everyone in your household.
(2) Write the amount of income received last month for each household member. This income is the amount before taxes or anything else is taken out, and where it came from, such as earnings, welfare, pensions, and other income (refer to examples below for types of income to report). If any amount last month was more or less than usual, write that person’s usual income.
(3) An adult household member must sign and give his/her social security number in PART 3
PART 2C – FOSTER CHILD: COMPLETE THIS PART and PART 3
(1) A foster parent or other official representing the child must sign the form in part 3.
PART 3 – SIGNATURE AND SOCIAL SECURITY NUMBER: ALL HOUSEHOLDS COMPLETE THIS PART.
(1) All eligible forms must have the signature of an adult household member.
(2) The adult household member who signs the statement must include his/her social security number. If he/she does not have a social security number, write “none” or other explanation to show that he/she does not have a social security number.
If you listed a food stamp, FDPIR or TANF identification number, a social security number is not required.
PART 4 - RACIAL/ETHNIC IDENTITY: (OPTIONAL) COMPLETE THE RACIAL/ETHNIC IDENTITY QUESTION IF YOU WISH. You are not required to answer this question to receive meal benefits. However, this information will help ensure that everyone is treated fairly.
INCOME TO REPORT
Earnings from Employment
Net income from self-owned business, day care business or farm
Public assistance payments
Alimony/child support payments
Supplemental Security Income
Social Security Income
Other Monthly Income/Self-employment
Cash withdrawn from savings
Income from estates/trusts/investments
Regular contributions from persons not living in the household
Net royalties/annuities/net rental income
Net Rental Income
Payment/reimbursements from fostering children
Any other income
Camp Ray Bird is participating in the Summer Food Service Program. Meals will be provided to all eligible children free of charge. Eligibility is determined by enrollment as a camper and completion of the summer camp application and income eligibility form. Children who are part of households that receive food stamps, or benefits under the FDPIR, or TANF are automatically eligible to receive free meals. Acceptance and participation requirements for the program and all activities are the same for all regardless of race, color, national origin, gender, age or disability, and there will be no discrimination in the course of the meal service. Meals will be provided at the site and times as follows:
Meal times are Breakfast-8:45, Lunch-12:45, Supper-5:30 Tuesday thru Friday, Monday Supper-5:30.
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: firstname.lastname@example.org.
This institution is an equal opportunity provider.