Food Pick up form

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Food Pick up form

CACFP food pick up
According to Waivers granted for non-congregate setting grab and go meal service to registered families for CACFP meals. You are authorizing the following people/group for food pick up and/or delivery.
DUE TO COVID-19 all Parent Transit enrollment and required forms including applications are being done digitally to make this process Contact-less to limit exposure.

Pursuant to the Pennsylvania DHS authorization:
55 PA CODE CHAPTERS 3270.117(c) and 3280.117(c) and 3290.116(c)
THIS FORM MUST BE COMPLETED TO DOCUMENT THE VERBAL REQUEST BY A PARENT FOR THE
RELEASE OF A CHILD TO A PERSON(S) NOT INDICATED ON THE AGREEMENT
(CHAPTERS 3270.123(a)(5), 3270.124(b)(7); 3280.123(a)(5), 3280.124(b)(7); 3290.123(a)(5), 3290.124(b)(7)).

In this case the release will be of child/children's meals (not the actual child/children per say) in a grab, go and delivery fashion utilizing CDC COVID-19 Contact-less methods.

Email *

Child/Children's Name? *

Parent/Caregiver Name? *

Parent/Caregiver Contact Number *

Delivery Address *

Delivery/Pick Up Time (We can only take this into consideration when designing service times) *

Time

Are you are current PELA Kids/William Bailey REC Center Inc. CACFP or SFSP Participant *

Yes

Interested in Signing up

Are you authorizing pick up of your child's meals? *

Yes, I'm Picking up

I authorize the Parent Pick Up Transportation Unit to Pick up meals on my child's behalf.

I decline the meals all together

Provide a Specific Gaudian Name

Parent Support Transit is an independent group of volunteers who I release my personal location, preferred communication methods and child/children name information for usage of their meal pick-up and delivery services on my behalf as my authorized Guardian. I also understand that this service is not paid through any PDE monies. Any monies collected are strictly on a donation/gift basis, not fees for any service. Furthermore, meals are delivered in a contact-less fashion and all meals are delivered frozen for food safety precautions. *

Yes, I Agree and Understand

No, I don't agree and decline this service.

I need more information, please call me.

When Do I want the pick up to start *

ASAP

In 2 weeks

In 1 week

Next Month

Free Meal Program Enrollment *

YES, I do not want to enroll my child/children in this program

NO, I do want to enroll my child/children in this program

Required

Acknowledgement, I understand that I will not be duplicating meal service(s) : getting the same type of meal (breakfast, lunch, etc.) from multiple free suppliers at the same meal service times and dates. *

Yes

Required

A copy of your responses will be emailed to the address you provided.

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