Meal Delivery Permission Form

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Galax City Public Schools plans to deliver meals door to door for students enrolled in virtual instruction. Breakfast and lunch will be provided to ALL students FREE of charge this year. Thank you for completing this form giving us permission to make deliveries to your child.

Parent/Guardian Name *

I, _________________ , give my permission for GCPS to deliver meals to my child(ren) enrolled at Galax Elementary School, Galax Middle School and/ or Galax High School.

Home Address *

Example: 123 Maroon Tide Dr. Galax, VA 24333

Where would you like your meals delivered?

Street Number *

Example: 123

Street Name *

Example: Maroon Tide Dr.

City, State, and Zip Code *

Example: Galax, VA 24333

Please provide students' names and grades below:

Student Name 1 *

Full Name

Grade (Student 1) *

Student Name 2

Full Name (If you don't have anymore students please scroll to the bottom.)

Grade (Student 2)

Student Name 3

Full Name (If you don't have anymore students please scroll to the bottom.)

Grade (Student 3)

Student Name 4

Full Name (If you don't have anymore students please scroll to the bottom.)

Grade (Student 4)

Student Name 5

Full Name (If you don't have anymore students please scroll to the bottom.)

Grade (Student 5)

Parent/Guardian Signature *

In accordance with Federal civil rights law and U.S. Department of Agriculture (USD A) civil rights regulations and policies, the USDA, its Agencies, offices, andemployees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, rehgiouscreed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language,etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contactUSDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint,and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaintform, caU (866) 632-9992. Submit your completed form or letter to USDA by:(1) mail: U.S. Department of AgricultureOffice of the Assistant Secretary for Civil Rights1400 Independence Avenue, SWWashington, D.C. 20250-9410;(2) fax: (202) 690-7442; or(3) email: program.intake@u$da.gov.This institution is an equal opportunity provider.

Date *

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