Consent for Disclosure
Sharing Information with Other Programs
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Dear Parent/Guardian:
You do not have to send in this form to get reduced price or free Child Nutrition Program benefits for your children.
To save you time and effort, information about your children’s eligibility for reduced price or free Child Nutrition Program benefits may be shared with other programs for which your children may qualify.  For the programs listed below, we must have your permission to share your information. *
I DO want school officials to share information about my children’s eligibility for Child Nutrition Program benefits with the programs I have checked below.
If you checked yes to any or all of the boxes above, fill out the form below. Your information will be shared only with the programs you checked.
Student's First Name (1): *
Student's Last Name (1): *
Student's Grade (1):
Student's Attendance Center (1):
Student's First Name (2):
Student's Last Name (2):
Student's Grade (2):
Student's Attendance Center (2):
Student's First Name (3):
Student's Last Name (3):
Student's Grade (3):
Student's Attendance Center (3):
Student's First Name (4):
Student's Last Name (4):
Student's Grade (4):
Student's Attendance Center (4):
Student's First Name (5):
Student's Last Name (5):
Student's Grade (5):
Student's Attendance Center (5):
Address:
City:
State:
Zip Code:
Digital Signature *
Typing your name below will act as a digital signature stating:  I certify that all the information on this form is true.
For more information contact: Stephanie Green, P.O. Box 289, Effingham, KS. 66023  913-833-4420 Ext 2214.

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

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

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at:  https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted 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; or

(2)   Fax:

   (833) 256-1665 or (202) 690-7442; or

(3)   Email:

    program.intake@usda.gov

This institution is an equal opportunity provider.


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