[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-535354-105":59,"doc-detail-535354-en":130},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":123,"head_meta":125,"extra_data":127,"updated_unix":129},105,"en","home-delivered-meal-request-and-consent-form-summer-food-service-program","HOME-DELIVERED MEAL REQUEST AND CONSENT FORM - Summer Food Service Program","","Home-delivered meal request and consent form for the Summer Food Service Program, collecting parent/guardian contact details, home delivery address, and children’s names and ages. It gathers delivery timing, planned vacation periods, and confirmation of access to water and kitchen tools for preparing and cooking meals. The form also requests information about food storage capacity for up to 10 days, special dietary needs and allergy substitutions, and legal consent for distributing meals only to eligible children in the household.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/home-delivered-meal-request-and-consent-form-summer-food-service-program/535354/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/home-delivered-meal-request-and-consent-form-summer-food-service-program/535354.png","ImageObject",300,407,{"name":92,"@type":93},"Riley West","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-19","2026-10-10",true,{"@type":102,"interactionType":103,"userInteractionCount":29},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What information must a parent or guardian provide on the form?","Question",{"text":112,"@type":113},"The form requests parent/guardian names, home-delivery address, contact telephone and email, and the names and ages of all children in the household.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What delivery and household capability details are collected?",{"text":117,"@type":113},"It asks about the time(s) meals will be received, planned vacation time (optional), access to water, kitchen tools for cutting and chopping, tools and appliances for cooking or heating, and whether an adult can assist as needed.",{"name":119,"@type":110,"acceptedAnswer":120},"How does the form handle special dietary needs and allergies?",{"text":121,"@type":113},"It asks whether the child(ren) have special dietary needs. If yes, the form requests an explanation and any acceptable substitutions for allergies.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},535354,1791715724,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":29,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":24},1099523885074,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","HOME-DELIVERED MEAL REQUEST AND CONSENT FORM  \n100 North First Street Springfield, Illinois 62777-0001  \nSUMMER FOOD SERVICE PROGRAM  \n\n| NAME OF PARENT(S)/GUARDIAN(S) |  |\n| --- | --- |\n| HOME DELIVERY ADDRESS (Include City, State, and ZIP Code) |  |\n| CONTACT TELEPHONE (Include area code) | CONTACT EMAIL ADDRESS |\n\nName(s) and ages of all children in the household:  \n\n| NAME | AGE |\n| --- | --- |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n\nDelivery Instructions: What time(s) of the day will you or your child(ren) be present to receive the meals delivered to your home? There may be instances when food items (e.g. , milk, produce) may require refrigeration.  \nPlanned vacation time when service is not needed (optional):  \nPlease indicate “Yes” or “No” to each of the following statements to help us provide meals that meet your needs:  \nNEEDS YES NO  \nI have access to water to wash and prepare food items.  \nI have access to kitchen tools used for cutting or chopping.  \nI have access to kitchen tools used to heat or cook food (e.g. , pot, pans) .  \nI have access to kitchen appliances for heating or cooking.  \nI or another adult will be available to help prepare food items, as needed.  \nSomeone in the household can read and understand preparation instructions, as needed.  \nPlease describe your homes food storage capacity and your ability to store up to 10 days’ worth of meals. (Refrigerator, freezer, ice box. , etc. )  \nISBE 67-34 ( 12/24)  \nDoes your child(ren) have any special dietary needs? YES  NO   \nIf yes, please explain what those needs are and who they are for. If there is an allergy to certain foods, please list acceptable substitutions:  \nI certify that all the information on this form is true and correct. I consent to receiving meals delivered by the Summer Food Service Program to my home for the child(ren) listed above, of which I am the legal parent/guardian. I understand that the meals provided are for children 18 and under residing in this household and shall not be distributed to others.  \nPrint Name Digital or Original Signature Date  \nFor all other FNS nutrition assistance programs, state or local agencies, and their subrecipients, must post the following Nondiscrimination Statement:  \nIn 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.  \nProgram 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.  \nTo file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online  \nat: [https://www.usda.gov/sites/default/files/documents/ad-3027.pdf](https://www.usda.gov/sites/default/files/documents/ad-3027.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:  \n1. mail:  \nU.S. Department of Agriculture  \nOffice of the Assistant Secretary for Civil Rights  \n1400 Independence Avenue, SW Washington,  \nD.C. 20250-9410; or  \n2. fax:  \n(833) 256-1665 or (202) 690-7442; or  \n[3","cbCaivXOYNq33aLc","https://ap.wps.com/l/cbCaivXOYNq33aLc","pdf",310367,"English","# Home-Delivered Meal Request and Consent\n## Household and Delivery Information\n## Delivery Instructions and Capability Questions\n## Certification, Signature, and Date\n## Nondiscrimination Statement","[{\"question\":\"What information must a parent or guardian provide on the form?\",\"answer\":\"The form requests parent/guardian names, home-delivery address, contact telephone and email, and the names and ages of all children in the household.\"},{\"question\":\"What delivery and household capability details are collected?\",\"answer\":\"It asks about the time(s) meals will be received, planned vacation time (optional), access to water, kitchen tools for cutting and chopping, tools and appliances for cooking or heating, and whether an adult can assist as needed.\"},{\"question\":\"How does the form handle special dietary needs and allergies?\",\"answer\":\"It asks whether the child(ren) have special dietary needs. If yes, the form requests an explanation and any acceptable substitutions for allergies.\"}]","HOME-DELIVERED MEAL REQUEST AND CONSENT FORM - Summer Food Service Program | PDF",1791600230]