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[]
[null,"                                                                                                                                                                                                                            SFSP/CACFP Home Delivery Statement and Parent/Guardian Pick-Up Procedures Statement\n"]
[null,"PART I: Preliminary Information"]
[null,"Sponsor Name:"]
[null,"Agreement Number:"]
[null,"PART II: Home Delivery "]
[null,"Number of Actual Sites using Home Delivery:"]
[null,"Home Delivery Agreement:\nBy clicking \"yes\" in Part II B, I certify that as a SFSP Program operator, I will:                                                                                                                               (1) identify and invite households of only eligible children to participate in the meal delivery service;\n(2) obtain written consent from households of eligible & enrolled children that the household wants to receive delivered meals.  The written consent will be obtained prior to providing meals to children;\n(3) confirm and maintain documentation supporting the eligibility and number of children being served;  \n(4) confirm the household's current contact information to ensure meals are delivered to the correct location;                                                   (5) confirm and maintain documentation supporting the number of meals delivered to each home; \n(6) ensure not to exceed the maximum number of meals per child per day; and\n(7) protect the confidentiality of participants and their households throughout the process in accordance with confidentiality and disclosure provisions in the National School Lunch Act and 7 CFR 225.15(f)-(l).\n\nAdditionally, I certify I will notify households if their contact information will be shared with any external organization. Households also must have a way of notifying the sponsor of the need for individual substitutions due to medical or other special dietary needs. (Note: Written consent may be issued by hard copy documentation, e-mail, or other electronic means of communication.  Written consent must be provided by the participant's parent or guardian). "]
[]
[]
[]
[null,"1. Individual Child Eligibility Information from School Data (for home addresses that are not area eligible)"]
[null,"The organization is utilizing school data to establish eligibility for each child.  If a non-SFA, the organization has secured written MOUs with an SFA to use the SFA's student data to establish the eligibility for meal recipients and certifies that no meals will be delivered to homes that are not supported by the eligibility data obtained from the SFA. The organization will maintain the supporting individual school data, the MOU (if applicable), and provide the documentation upon request. "]
[null,null,null,null,null,"Yes     ","   No","   N/A (homes are area eligble)"]
[null,"2. Income Eligibility Statements (for home addresses that are not area eligible)"]
[null,"The organization has secured Income Eligibility Statements (IES forms) to identify eligible children and certifies that meals will only be delivered to households that qualify as free or reduced. The organization will maintain all IES forms and provide the forms upon request. "]
[null,null,null,null,null,"Yes     ","   No","   N/A (homes are area eligble)"]
[null,"PART II B: Home Delivery Certification"]
[null,"I certify/attest to the statements in the above section."]
[null,null,null,null,null,"Yes     ","   No"]
[]
[null,"PART III: Parent/Guardian Pick-Up Meal Service Option "]
[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 1 will be used",null,null,null," Yes     ","   No"]
[]
[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.)"]
[null,"Option 2 will be used",null,null,null," Yes     ","   No"]
[]
[null,"Option 3: (Other): I will verify the participant’s name and identity by utilizing a method other than those listed above. \n(Note: If selecting this option, please explain your proposed method of verification in the box below.)"]
[null,"Proposed Method of Verification:  "]
[null,"PART III B: Parent/Guardian Pick-Up Certification"]
[null,"I certify/attest that if approved to utilize the Parent/Guardian Pick-up, neither myself or the approved organization will distribute duplicate meals to a child and/or adult participant. "]
[null,null,null,null,null,"Yes  ","No"]
[null,"PART IV: Certification Statement"]
[null,"I certify/attest 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,null,"Yes","No"]
[null,"PART V: Signature"]
[null,"Electronic Signature of Program Contact or Authorized Representative: ",null,null,null,null,null,"/s/   [TYPE YOUR NAME HERE]                  [TYPE THE DATE HERE]  "]