CACFP Disaster Milk and Meal Flexibility Request

1
Image Field
2
CACFP Disaster Milk and Meal Flexibility Request This request form is strictly for CACFP facilities that are under the sponsorship of Youth Educational Services, Inc. (YES Inc). Please contact Bright from the Start or your sponsor for flexibility during disasters. DECAL state-level flexibility will only be granted to those impacted organizations, sites, or individuals located in a state in which a “State of Emergency” has been declared. In determining whether a “State of Emergency” exists in Georgia, the definition of “State of Emergency” provided in Part I of this document shall be applied. FOOD COMPONENT- You may make requests for the following: - Services without milk or an alternate form of milk (e.g., canned or dry) - Special variations in menu planning and meal pattern (requires permission from USDA) MEAL SERVICE - You may request the following: - Temporary changes in the time of meal service Complete the form below for us to submit your request to DECAL. If we have further questions, Please contact us immediately for further guidance. 770-938-3188 Once submitted, you will have CONDITIONAL permission to make the substitution; however, you will not be reimbursed for meals if DECAL or USDA-FNS reject your request. If you have any questions, contact YES Administration.
3
Your Business Name* This field is required.Child Care Center Name
4
Your Name* This field is required.
First Name
Last Name
5
Email* This field is required.Email (A copy of your responses will be sent to this email. Make sure it is correct.)
6
Program Type* This field is required.You may select more than one
Child Care Center
Adult Care Center
At-Risk Afterschool Program ONLY
Homeless Shelter
7
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
GA
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
County/School DistrictEx. (Dekalb County)
9
Telephone Number* This field is required.Phone Number to contact you directly about this request
Area Code
Phone Number
10
Mobile/Alternate Number* This field is required.
Area Code
Phone Number
11
Center Operating HoursUpdated hours due to COVID-19 (if applicable)
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
Until
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
12
MEAL SERVICE REQUEST- Are you requesting a TEMPORARY meal time change?
YESNO
13
Breakfast Time (If changed due to COVID-19 (if applicable)
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
15
30
45
Minutes
AM
AM
PM
Until
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
15
30
45
Minutes
AM
AM
PM
14
Lunch Time (If changed due to COVID-19 (if applicable)
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
15
30
45
Minutes
AM
AM
PM
Until
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
15
30
45
Minutes
AM
AM
PM
15
PM Snack Time (If changed due to COVID-19 (if applicable)
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
15
30
45
Minutes
AM
AM
PM
Until
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
15
30
45
Minutes
AM
AM
PM
16
Dinner Time (If changed due to COVID-19 (if applicable)
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
15
30
45
Minutes
AM
AM
PM
Until
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
15
30
45
Minutes
AM
AM
PM
17
Evening Snack Time (If changed due to COVID-19 (if applicable)
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
15
30
45
Minutes
AM
AM
PM
Until
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
15
30
45
Minutes
AM
AM
PM
18
Nearest Elementary School to the CenterPLEASE NOTE: Many county schools will provide lunch for pick up for anyone 18 years of age or younger between the hours of 11 a.m. and 1 p.m. These lunches will be provided at no cost to the individual through the federal School Nutrition Program. The student or child must be present to receive the meal. A child does not have to be a student at the school site to receive a meal.
19
FOOD COMPONENT REQUEST- Describe the nature of your request. Be very specific with details and vendors you have visited. What is the emergency? What difficulties are you having? What have you recently done to purchase the exact food components you need? If milk is an issue, what type of milk are you having difficulty finding?Example: All of the store are closed in my area. Whole grain options are not available, we would like to get approval to serve non-whole grain options.
20
Item 1. What are you proposing to substitute in place of the item(s) you cannot find? Example: We can not find 1% Fluid Milk in the stores. We are asking for a waiver to be approved to use 2% milk instead.
21
Item 2. What are you proposing to substitute in place of the item(s) you cannot find?Example: We can not find 1% Fluid Milk in the stores. We are asking for a waiver to be approved to use 2% milk instead.
22
Item 3. What are you proposing to substitute in place of the item(s) you cannot find?Example: We can not find 1% Fluid Milk in the stores. We are asking for a waiver to be approved to use 2% milk instead.
23
Item 4. What are you proposing to substitute in place of the item(s) you cannot find?Example: We can not find 1% Fluid Milk in the stores. We are asking for a waiver to be approved to use 2% milk instead.
24
* This field is required.
25
Name of Authorized Personnel
First Name
Last Name
Should be Empty: