Feed-A-Kid Referral Form
Student's First Name
Student's Last Name
Extreme hunger on Monday morning
Quickly eating all of the food served & asking for more
Asking when the next meal/snack will be served
Lingering around or asking for seconds
Comments about not having enough food at home
Asking classmates for food they don't want
Other information about the child's food insecurity
Chronically dry/cracked lips
Chronically dry/itchy eyes
Short Attention Span
Chronic Behavior Probelms
Often cooks own meals or sibling cooks meals
Loss of household income
School has notified the parent that their information will be shared with Thermal Belt Outreach Ministry
School has Parent & Child's agreement to participate in the Fed-A-Kid program.
Name of person making the referral...
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This form was created inside of Polk County Schools.