SUMMER FOOD SERVICE PROGRAM 2023 SITE APPLICATION

SUMMER FOOD SERVICE PROGRAM

2025 APPLICATION FORM
Please COMPLETE each section. DO NOT LEAVE any section blank:
Site Info*

NEW SITE (Pre-Approval needed)Previous Year ParticipationChange of Name (Pre-Approval needed)Change of Address Pre-Approval
1) * NAME OF MAIN ORGANIZATION*
Address*
* City*
State*
Zip*
* Phone*

Area CodePhone Number
* Coordinating Supervisor’s Name*
* E-mail Address*
example@example.com
2) NAME OF SITE SERVING MEALS*
Serving site address*
City*
State*
Zip*
Phone*

Area CodePhone Number
Fax*
Write NA if no applicable
3.) Two names and positions of people serving meals at site

both must attend mandatory training.

There is a mandatory ratio of 1 person serving meals to 25 participants receiving meals during each service shift.
Prefix for 1st Person*

Mr.Mrs.Ms.Rev.
Name*
Position*
Prefix for 2nd Person*

Mr.MrsMs.Rev.
Name *
Position*
4. Type of Site: Check One Only*

Recreational CenterSchoolSummer CampPublic HousingParkChurchSocial ServicesOther (Specify)
Note: Earliest time meals can be delivered to site: Ex: 7:00 (AM)*
Please provide a minumum of a 30-minute time frame before meal service.
There must be a three-hour period between the beginning of one
meal period and beginning of another. Breakfast can last 1 hour;
Lunch can last 2 hours; Snack 1 hour; Supper can last 2 hours BUT
NOT PAST 5:00 P.M
Example: Lunch Served – From: 12:00 to 2:00 pm (2hrs.)

Snack Served – From: 3:00 to 4:00 pm (1 hr.)
Site can select to serve up to two meal types BUT cannot select to serve both Lunch AND Supper together for their program.
SELECT UP TO TWO MEALS FOR EACH SITE
# of BREAKFAST MEALS*
Type NA if not applicable
From*
To*
# of LUNCHES MEALS*
Type NA if not applicable
From*
To*
Please select Hot/Cold*

HotCold
# OF SNACKS MEALS *
Type NA if not applicable
From*
To*
# OF SUPPER MEALS*
Type NA if not applicable
From*
To*
Site Operating Date

Note: The Program will be serving meals from June 12, 2023 to August 16, 2023 (Ten Weeks)
Site Beginning Date:*

MonthDayYear
Date
Site Ending Date:*

MonthDayYear
Date
Total number of weeks*
Adequacy of site
9a. Does site have adequate equipment to keep food warm? Warmer/Oven/Steamtable)*

YesWarmerNoOvenSteamtable
9b. Does site have adequate equipment to keep food cold? (Refrigerator/Cooler)*

YesCoolerNoRefrigerator
9c. Does site have the ability to properly sanitized serving utensils? (hot water/sink)*

YesHot waterNoSink
10 Does the site have indoor facilities or shelter in case of inclement weather?*

YesNo
11). List the name of Dade County Public School(s) attended by children at the site: (List more than one if applicable)
1.*
2.*
12.) What types of organized activities are planned at the site other than the meal program?
1. *
2.*
3.*
Participation on the program will be based on approval of application, site, inspection, signed agreement.
ALL NON-PROFIT ORGANIZATIONS MUST SEND COPY OF CURRENT 501 (C) (3) CERTIFICATE
Signature*

Clear
Position*
Date*

MonthDayYear
Date
If you need further information please contact: Olive Cooper at 305-234-1645 or info@kb-florida.org
Should be Empty:

SUMMER FOOD SERVICE PROGRAM

Site Operating Date