Consent for Disclosure Sharing Information with Other Programs
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.
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.
If you checked yes to any or all of the boxes above, fill out the form below. Your information will be shared only with the programs you checked.
Signature of Parent/Guardian
For more information, you may call or email:
School Official's Name: Summer Warren
This institution is an equal opportunity provider.