At-Home Meals Consent Form-SFX

At-Home Meals Consent Form

St. Francis Xavier
This form must be filled out and submitted by 3pm Friday, October 2 in order to receive meals on Tuesday, October 6. If you have already signed up for the quarter, you do not need to fill this form out again. Meals will be packaged and ready for pick up at your school site every Tuesday between 12:30pm and 1:30pm. For questions, please contact the Child Nutrition Program at (225)-387-6421.
- Meals will be distributed at no cost.
- Only one breakfast meal and one lunch meal per enrolled student per day may be requested (up to 5 breakfast meals and 5 lunch meals per week).
- Students receiving meals must be enrolled in virtual learning or under temporary quarantine.
Name of parent/guardian:
Phone:
Email Address:
example@example.com
Please indicate how often you will be picking up meals.

I will be picking up meals for the entire quarter. I will be picking up meals during quarantine for this week only.
I will be picking up blanks breakfast meals andblank lunch meals per child each week.
1. Student Name
1. Student ID Number
2. Student Name
2. Student ID Number
3. Student Name
3. Student ID Number
4. Student Name
4. Student ID Number
5. Student Name
5. Student ID Number
Signature of person picking up meals

Clear
Print name of person picking up meals
*Signature of parent/guardian

Clear
Date

Month Day Year
Date
Parent/guardian signature implies consent for meal pick-up; appropriate meal charged to student’s account as determined by student’s full price, reduced price or free meal status on file; and meal received is solely for the student listed above.

This institution is an equal opportunity provider.
Should be Empty: