At-Risk Afterschool Information

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Complete and submit this form to determine if your At-Risk Afterschool program is eligible. The Department of Public Instruction staff will review the information and contact your program with the next steps.

Agency Name (Legal Name) *

Authorized Representative (First and Last Name) *

The Authorized Representative is the official within the organization with the legal authority to enter into contracts and execute such documents on behalf of the organization. The signature of the Authorized Representative certifies that the organization agrees to conform to the CACFP regulations, guidelines, and policies. The Authorized Representative may or may not complete any or all CACFP tasks but is ultimately responsible for the CACFP.

Authorized Representative E-mail address *

Person Responsible for CACFP (If different from Authorized Representative)

Person Responsible for CACFP E-mail address (If different from Authorized Representative)

Are you an existing School Food Authority (SFA) interested in serving meals in your At-Risk Afterschool Program? *

Yes

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