Consent for Disclosure

Consent for Disclosure Sharing Information with Other Programs

Dear Parent/Guardian:

You do not have to sign or send in this form to get reduced price or free Child Nutrition Program benefits for your children. If you do not sign the Consent for Disclosure, it will not affect eligibility for or participation in the Child Nutrition Programs.

To save you time and effort, information about your children’s eligibility for reduced price or free Child Nutrition Program benefits may be shared with other programs for which your children may qualify. For the programs listed below, we must have your permission to share your information.

Sign in to Google to save your progress. Learn more
Email *
Yes, I DO want school officials to share information about my children’s eligibility for Child Nutrition Program benefits only with the programs I have checked below.
Check next to each program you want school officials to share information with below

Student Fees waived with FREE application or FREE Direct Certification

Clear selection

Discounted Technology Fees, FREE & REDUCED application or Direct Certification_

Clear selection

Discounted Fees (SAT, ACT) FREE & REDUCED application or Direct Certification

Clear selection

If you checked yes to any or all of the boxes above, list your children's names AND school they will attend below. Your information will be shared only with the programs you checked. 


Example: John Smith - Prairie Hills Middle School
Student 1 *
Student 2

Student 3
Student 4
Student 5
Student 6
Parent/Guardian signature

By typing your name below you certify (promise) that you are the parent/guardian of the students listed above and that your electronic signature is equivalent to a print signature and is legally binding.  You also agree for your information to be shared with the programs checked for question 1.
Please list the address of the parent/guardian filling this out.

For more information, you may call or e-mail:
School Official’s Name: Robin McGlynn Phone: 620-543-5617 E-Mail: rmcglynn@usd313.org Return this form to the address below within 2 weeks of application or Direct Certification letter. Address: 10400 E. 69th Buhler KS 67522

NON-DISCRIMINATION In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: mail:        U.S. Department of Agriculture                  Office of the Assistant Secretary for Civil Rights                  1400 Independence Avenue, SW                  Washington, D.C. 20250-9410 fax:          (833) 256-1665 or (202) 690-7442; or email:      program.intake@usda.gov This institution is an equal opportunity provider.

A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Buhler USD 313. Report Abuse
Google Forms