Step 1 of 4

1. SITE NAME*

2. SITE PHYSICAL ADDRESS (this is the location of food service):*

Street Address City State ZIP Code

COUNTY*

County

Nearest Cross Streets*

Nearest Cross Streets

3. DELIVERY DETAILS & SPECIAL INSTRUCTIONS (Non-rural sites receiving only shelf-stable meals must pick-up meals at our 45th Ave warehouse weekly. This does not include rural non-congregate or Western Slope sites.)*

Include here specifications on where drivers should be leaving your delivery. Some examples of what to include are: building or room number, what entrance to use, where they can park, any building entry instructions/passcodes/phone numbers they would need, if staff will be on site to meet them, etc.

What is your delivery window?*

We have specific time

N/A – pick-up only

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4. SITE CONTACT INFORMATION

Though duties may be delegated, this listing should be the person(s) responsible for the site and all program paperwork. At least one of these individuals will be required to attend training.

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Primary Contact

First Name*

Last Name*

Phone Number*

Alternate Phone

Email*

Title*

Secondary Contact

First Name*

Last Name*

Phone Number*

Alternate Phone

Email*

Title*

5. AGE RANGE OF PARTICIPATING CHILDREN*

Must be between 5 and 18 years.

6. DOES THIS SITE PARTICIPATE IN ANY OF THESE OTHER USDA PROGRAMS? (check all that apply)*

National School Lunch Program (NSLP)

School Breakfast Program (SBP)

Child and Adult Care Food Program (CACFP)

Special Milk Program (SMP)

None of These

7. SITE TYPE:*

Open: Located in an eligible area and meals are available to all children in the area on a first-come, first served basis.

Restricted Open: Located in an eligible area with meals available on a “first-come, first-served“ basis but service of meals may be limited due to reasons of space, security, safety, or control.

Closed Enrolled: Service is open only to enrolled children as opposed to the community at large. The site may establish eligibility by 1) collecting income eligibility forms with at least 50% of the enrolled children being eligible for free or reduced-price school lunches, or 2) by using area eligibility information provided by their local school district documenting that at least 50% of the children served by the nearest school are eligible for free or reduced-price school lunches. Accredited summer schools do not qualify as closed enrolled sites.

Reason for operating a Restricted Open site*

Reason for operating a Closed Enrolled site*

Is this a non-profit site?*

Yes

8. IS THIS SITE ASSOCIATED WITH AND/OR OPERATED BY A PUBLIC HOUSING AUTHORITY?*

Yes

If yes, what is the name of the public housing authority?*

9. IS THE SITE OPEN ONLY TO ENROLLED SUMMER SCHOOL STUDENTS WHO RECEIVE ACADEMIC CREDIT?*

Yes

10. DID THIS SITE PARTICIPATE IN SFSP LAST YEAR?*

Yes

11. ELIGIBILITY: Choose one of the below methods on which you are basing your eligibility.*

School Data: Provide the closest eligible school to your site location. If this site is located at a school, you may list your own location so long as it’s eligible.

Closed Enrolled Site Information

Public School District*

School Name*

Percent Eligible for Free and Reduced Lunches*

Program Year of School Data*

Projected Number of Enrolled Children*

Projected Number of Enrolled Children Who are Eligible to Receive Free or Reduced-Price Meals*

Percentage of Enrollment Eligible for Free and Reduced-Price Meals:*

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12. RACIAL AND ETHNIC DATA

Ethnic Categories

Number of Participating Not-Hispanic or Latino Children*

Number of Participating Hispanic or Latino Children*

Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term “Spanish origin” can be used in addition to “Hispanic or Latino.”

Racial Categories

Number of Participating American Indian or Alaska Native Children*

Number of Participating Asian Children*

Number of Participating Black or African American Children*

Number of Participating White Children*

Number of Participating Native Hawaiian or Other Pacific Islander Children*

American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community recognition.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American: A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” can be used in addition to “Black or African American.”

White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

The sponsor should complete this form for each site under its sponsorship each year. Sponsors of residential camps must collect this information for each camp session.
On May 17th, 2021, USDA released CACFP 11-2021, SFSP 07-2021 Collection of Race and Ethnicity Data by Visual Observation and Identification in the Child and Adult Care Food Program and Summer Food Service Program – Policy Recission. Racial and ethnic data may no longer be collected by visual observation in the SFSP.
Sponsors must collect self-reported data from participants to the maximum extent possible. Sponsors may use data that participants self-report through program enrollment, school data, census data, or CDE data.
All line items on this page must be answered numerically (no percentages).
The sponsor must retain racial and ethnic data for three years, plus the current year, and must safeguard this information to prevent its use for discriminatory purposes. Access to program records containing racial and ethnic data should be kept confidential and limited to authorized personnel.

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13. START AND END DATE OF MEALS

The start date cannot be before the end of the 2024-2025 school year. The end date cannot be after school has started up again in the fall.

START DATE OF MEALS*

Start Date of Meals

END DATE OF MEALS*

End Date of Meals

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14. NUMBER OF DAYS SITE WILL OPERATE AND SERVE EACH MONTH:

14. NUMBER OF DAYS SITE WILL OPERATE AND SERVE EACH MONTH

Do not count days you will not be serving.

June*

July*

August*

15. TOTAL NUMBER OF DAYS SITE WILL SERVE (add together all months)*

16. INDICATE ANY SCHEDULED CLOSURES WHEN YOU WILL NOT BE SERVING MEALS:*

Unexpected closures must be reported immediately to Food Bank of the Rockies staff

17. SCHEDULED FIELD TRIPS:*

Indicate dates and locations for each field trip. Food Bank of the Rockies must be notified before taking meals offsite. An additional form will need to be submitted for each field trip.

18. IS THIS AN INDOOR OR OUTDOOR SITE?*

Indoor

Outdoor

Other

If this is an outdoor site, indicate your plan for serving meals during inclement weather*

Move service indoors

Serve under a canopy or other shelter

Cancel meal service

Please provide an explanation*

19. MEAL TYPE*

Approved sites may be allowed to serve up to two meals a day as long as one meal is a breakfast.

Breakfast

Lunch

Supper

Meal Type for Breakfast*

Fresh Meals (must serve at least 30 kids per day)

Shelf Stable “Super Snack” Meals

How many kids to you anticipate serving each day?*

Meal Type for Lunch*

Fresh Meals (must serve at least 30 kids per day)

Shelf Stable “Super Snack” Meals

How many kids to you anticipate serving each day?*

Meal Type for Supper*

Fresh Meals (must serve at least 30 kids per day)

Shelf Stable “Super Snack” Meals

How many kids to you anticipate serving each day?*

Summer Food Service Program (SFSP) Program Application

IMPORTANT DATES / DEADLINES

ALL SECTIONS MUST BE COMPLETED. INCOMPLETE APPLICATIONS MAY DELAY THE START OF THE PROGRAM.

RURAL SITES ONLY

MANDATORY TRAINING

PARTNER AGREEMENT & NOTICE TO PARTNER