Community Assistance School Lunch Program Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The Community Assistance School Lunch Program is a temporary, short-term assistance program that provides financial support to students who are in need. The program is funded by the generous donations of local organizations, community members and Derby Public Schools patrons.

Funds are awarded based upon availability, eligibility determination, and on a first come, first served basis. The funds are available on a temporary basis only. Long term assistance is available by completing an application for free and reduced price meals.

Parents, guardians, caregivers and students who are 18 years of age or older may complete an application. Documentation may be required to show financial hardship.

To apply for the Community Assistance School Lunch Program please complete this online form or fill out a paper application found at any school office or at the Central Kitchen, 610 E Market, Derby KS 67037.

For more information or if you have questions, please contact Martha Lawson, food service supervisor at (316)788-8419.

Todays Date

YYYY

Student Names *

Student Names

Please explain your current financial difficulty for which you are requesting assistance. *

What is your long-term solution to manage this hardship beyond the community funding period? *

This program provides payment, on a temporary basis, for school meals for students who are facing financial hardship. How many meals are you requesting per student?

If you are a student who is 18 or older and applying for funds, do you eat breakfast at school?

Yes

Clear selection

Does your student(s) eat breakfast at school?

Yes

Clear selection

List the names of the adult household members that we may speak with should there be questions about this application. Include the phone number for each adult. *

Current, working phone number. *

E-mail address that is read regularly *

Address (street, city, zip code) *

Name of the person submitting this request. *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Derby Public Schools. Report Abuse

Forms