22/23 UPLIFT Pine River Kids:  Food Backpack Program Application
Uplift Pine River Kids is a community supported food program for Pine River students. Uplift’s goal is to supply families/students with extra food on the weekends and holidays during the school year. The bags of food will be delivered to your student’s locker after school. They are placed in the student’s locker by a staff member. Uplift does not know any student’s name. We are just given a number of bags to be delivered to each building. Parents may pick up family members' bags. If you are stretching your budget to purchase food for your family, let Uplift help you. Students in grades 8-12 may receive the traditional bag or a to-go snack bag, or both. Uplift’s goal is to make sure no student goes hungry. Please fill out the form below to apply.    
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Today's Date *
Parent/Guardian Name: *
Address: Street, City, State and Zip Code *
Contact Phone Number *
Total number in household *
Please provide the first and last name of each child to receive Uplift bags AND list their grade in school. *
Please check the box of the school(s) your child(ren) attend.  Check all that apply *
Required
GRADES 8-12 ONLY:  Students in grades 8-12 have the option to receive a traditional bag, a snack bag, or both.  Please indicate your option for your 8-12 student(s). *
Please read the statement below if you wish to receive  the backpack program. You agree that you are 1. In need of food , are unable to meet the food needs of your family, or in a food emergency. (This is not based on income) or participate in WIC, Snap ,etc. 2. Your student has your permission to receive Uplift bags that may contain USDA products. 3. You agree to check food for your students food allergies.  Please sign and date below if you agree. *
USDA Non-Discrimination Policy
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs).  Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form.  To request a copy of the complaint form, call (866) 632-9992.  Submit your completed form or letter to USDA  by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.

USDA is an equal opportunity provider, employer, and lender.
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