SELF CERTIFICATION: CIVIL RIGHTS TRAINING

SELF CERTIFICATION: CIVIL RIGHTS TRAINING
If you have not already done so, please review the training slides below prior to signing the self-certification of training.
I hereby certify that I have reviewed and understand the civil rights training as required by United States Department of Agriculture regulations relative to my duties as staff/volunteer for:
Select the program types that apply to you:

Food Pantry, Mobile Pantry, Children's Produce Market, Backpack program using TEFAP FormsSenior Food Box Program (CSFP) Sub-AgencySoup Kitchen or Community Meal ProgramResidential Program with Meal ServiceMeals for daycare, healthcare or as part of other programming (adult or children)CEO Weinberg Food Bank Staff ONLY (TEFAP)CEO Weinberg Food Bank Staff ONLY (CSFP)Backpack program or other school program not using TEFAP forms
Date*

MonthDayYear
Date
County*
Full Name*
Agency Name - please include your agency's full name, including any program designations or specific locations, if applicable.*
Agency ID# - if known
Please select your role at the agency:*

Person In ChargeStaff or volunteer
Signature*

Clear
Email (to receive a copy of your training certification)
example@example.com
PRINT & RETAIN A COPY OF THIS SELF-CERTIFICATION FOR PRESENTATION WHEN REQUESTED DURING A FIELD STAFF MONITORING REVIEW
THANK YOU!
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