Application for Freshwise Summer Meals 2015

Application for Freshwise
Summer Meals 2015
APPLICATION DEADLINE IS MAY 15, 2015
SECTION 1: PROGRAM/AGENCY INFORMATION*
*All information in Section 1 is required
Program title:
Agency name:
Program location (full address):
Mailing address (if different):
Phone number:
Fax number:
Program Contacts:
EMAIL
NAME
Director/Supervisor:
Primary Contact:
Secondary Contact:
Program dates: Start date
End date
Participant Age Range:
Daily Planned Enrollment:
Program schedule: (Mark all that apply)
Monday
Tuesday
AM
Daily program hours: Opens at
PM
Wednesday
Thursday
Friday
AM
Closes at
PM
SECTION 2: SUMMER MEALS FOOD SERVICE REQUEST
BREAKFAST SERVICE
Requested:
Yes
Meal service time:
No
to
Requested days:
Mon
Tues
Expected participant high:
Wed
Thurs
Fri
Expected participant low:
*Note: there must be a minimum of 1.5 hours between breakfast and lunch
LUNCH/DINNER SERVICE
Requested:
Yes
Meal service time:
No
to
Requested days:
Mon
Tues
Expected participant high:
Wed
Thurs
Fri
Expected participant low:
*Note: there must be a minimum of 1.5 hours between snack and lunch/dinner
SNACK SERVICE
Requested:
Yes
Meal service time:
No
to
Requested days:
Mon
Expected participant high:
*Note: there must be a minimum of 1.5 hours between snack and dinner
Tues
Wed
Thurs
Fri
Expected participant low:
Application for Freshwise
Summer Meals 2015
APPLICATION DEADLINE IS MAY 15, 2015
Special considerations or other information:
Are you aware of any other programs at your site? If so, please list below:
Program:
Phone:
Email:
Program:
Phone:
Email:
Program:
Phone:
Email:
Please submit all applications to:
Freshwise
138 Joseph Avenue
Rochester, NY 14605
Attn: Dorthea King-Simpson
Nutrition Programs Coordinator
Phone: 254-4423
Fax: 647-2808
Email: DKing@foodlinkny.org