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[]
["PARENT/GUARDIAN PICK-UP WAIVER FORM                                                                                                                                                                                                                                                                                                                                                                                                                               (Applicable to both CACFP & SFSP)"]
["Form Instructions: Please carefully complete the required information below if requesting to utilize the Parent/Guardian Pick-Up waiver. Once the form has been completed, review it for accuracy, and send it to Leslie Truman at Leslie.Truman@decal.ga.gov. **Approval of this request will also require approval of the non-congregate feeding waiver and the meal times waiver. Submission of these waivers can be done by completing DECAL's Combined Waiver Form.                                                                                                                                                                                                                               Note: For questions concerning SFSP and/or CACFP application approval, please e-mail your assigned Application Specialist. "]
["Today's Date:"]
["Organization Name:"]
["Agreement Number:"]
["Program Type:",null,null,"CACFP ","SFSP ","Both "]
["All Sites Participating (Yes/No):",null,null,null,"If \"No,\" please indicate the total number of actual sites under waiver."]
["Number of Actual Sites under Waiver:"]
[" Meal Distribution Methods (Please select all that apply)"]
[null,"Option 1: I will ask the parent/guardian to present a form of valid child or adult identification (ID). Valid forms of ID may include, but are not limited to, school identification card, participant’s passport, government-issued child identification card, or any document proving parent/guardian identity and relationship to the child or adult, such as an adoption decree; doctor, clinic, or hospital record; religious record; or daycare center record."]
[]
[null,"Option 2: I will create a daily parent/guardian pickup roster by collecting the parent and/or guardian name, number of participants in the household, and names of participants in the household. (Note: If choosing this option,  DECAL recommends that collection of household information be done by the Program sponsor’s staff to minimize contact.)"]
[]
[null,"Option 3: (Other): I will verify the participant’s name and identity by utilizing a method other than those listed above. (Note: If selecting this option, please explain your proposed method of verification in detail below.) "]
[]
["Certifications (Please check Yes or No)"]
[]
["[1] I certify that if approved to utilize this waiver, neither myself or the approved organization will distribute duplicate meals to a child and/or adult participant. "]
[null,null,null,null,"Yes","No"]
["[2] I certify that if approved to utilize this waiver, all meals served by myself or by my organization will be distributed in accordance with Gov. Brian Kemp’s Executive Order dated June 11, 2020, which provides in relevant part, “Gathering\" shall mean more than fifty (50) persons physically present at a Single Location if, to be present, persons are required to stand or be seated within six (6) feet of any other person. Therefore, groups of more than fifty (50) people are permitted if their grouping is transitory or incidental, or if their grouping is the result of being spread across more than one Single Location.”  [Executive Order No. 06.11.20.01]"]
[null,null,null,null,"Yes","No"]
[" [3] I certify that the information contained within this entire document is true and correct to the best of my ability and that intentionally listing false or inaccurate information and/or failure to notify DECAL when the information contained in this document changes, may result in the denial of a claim(s) for reimbursement and/or termination and disqualification of the organization, its responsible principals and/or individuals from participation the in CACFP, SFSP, or any other Child Nutrition Program (CNP)."]
[null,null,null,null,"Yes","No"]
["Electronic Signature of Program Contact or Authorized Representative: /s/   [TYPE YOUR NAME HERE]"]

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[]
["Yes"]
["No"]