AFTER SCHOOL SNACK REQUEST FORM & CHECKLIST FOR QUALIFYING

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After School Snack

After School Snack

Request Form & Checklist for Qualifying

Revised July 2020



Submit completed form to School Nutrition Manager

APPROVAL REQUIRED TWO WEEKS PRIOR TO THE BEGINNING DATE OF PROGRAM



Program Name / School:


Snack Start Date: Snack End Date:


Time School Day Ends: Time Snack Starts:


Checklist Item

Answer Questions Below

What educational or enrichment component does your after school program have? Describe.

Describe Educational/Enrichment Component:




Students must be in PK – 12 grade to participate.

List AGE/GRADES of students participating:




A schedule is important in having snack available as needed.

Also, note any additional information, such as if your group is meeting every other week, etc.



Check each day of the week program will meet:







M T W TH F

Additional Information:


Enrollment determines the number of snacks that can be available for a group. (Only one snack per day per student is allowed.)




Estimated snacks needed daily:



List numbers below if enrollment varies daily:






M T W TH F


Location where snacks will be served.

Please be specific.



Name of Room and/or Room number.


Applicant Name:

Contact Number: _________________________ (w) _________________________________ (c)

Email: _____________________________ @clevelandcountyschools.org or/ other email address

Email:


Date ________________________________



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