Summer Meal Guardian Pick up form

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

Sebring School District is approved to provide grab and go meals to children in eligible rural areas. Eligible participants include children ages 18 and under or persons 19 and over who are mentally or physically disabled and participating in a public or private non-profit school program for the mentally or physically disabled.

Per program regulations, Sebring School District may allow parents or a designated guardian to pick up meals on behalf of children. A designated guardian may include another adult, such as a grandparent or babysitter functioning as the child’s caretaker; or siblings, that have documented permission by the parent or legal guardian to pick up meals for the child. Childcare providers and individuals not listed on this form may not pick up meals for a child. If the child is present at the meal pick up, no special permissions are required.

Meals are provided free of charge from June 2, 2025 through August 7, 2025. Each grab and go meal box will contain 1 hot lunch meal and 1 breakfast meal.

Meals can be picked up at:

Sebring McKinley High School

225 East Indiana Avenue

Door D6

June 2, 2025 – August 7, 2025

Monday – Thursday 11am-1130am

This institution is an equal opportunity provider

List the name(s) of all children receiving grab and go meals (child's legal name) *

Name of Authorized Individual(s) and relationship *

I authorize the above individuals to pick up meals for the listed children. Any individual not listed may not pick up meals for my children. *

Yes

Required

Certifications (check all that apply) *

☐ I understand it is my responsibility to ensure the proper storage and preparation of meals once received.

☐ I understand the child(ren) listed is only eligible to receive one meal per meal service type (i.e. Breakfast, Lunch, Supper, Snack).

☐ I agree to follow all food safety instructions included with the meals.

☐ My child[ren) are not formally enrolled in child care with the individual(s) authorized to pick up meals.

☐ I certify the child(ren) listed is ineligible to receive meals provided through another Child Nutrition Program such as the Child and Adult Care Food Program, Summer Food Service Program, or Seamless Summer Option if I choose to enroll in grab and go meals.

☐ I certify that all information on this form is true.

Required

Parent/Legal Guardian Printed Name *

Date: *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of ACCESS.

Does this form look suspicious? Report

Forms