Food Assistance Request Form

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

This form will be used by the District to collect the needed information to deliver meals for those families that are unable to pick-up food at Southern Middle School on Monday, Wednesday and Friday from 11AM - 12PM.

Please contact Jill Platts for any questions you have when completing this form or if you are in need of non-food assistance. Her email address is jill.platts@sycsd.org and phone number is or at 717-235-4811 extension 4571.

Email *

Parent or Guardian Name *

Phone Number (to be reached during the delivery time) *

Number of children 18 years old and under in your household (you can include those younger than school aged) *

Other:

Please provide the names of your children identified above. *

Please list any food allergies in your household that we need to be aware of.

Please provide your home address for delivery purposes. (House Number, Street Name, Zip Code or Town) *

We are required to receive consent by the parent or guardian to deliver meals to the household. By checking the "Yes" box below, you are providing your consent as well as confirming the number of students in the household and your address. *

Yes

Required

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Southern York County School District. Report Abuse

Forms