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Sack Summer Hunger Enrollment Application

Registration begins on April 15 and ends on May 20

Sack Summer Hunger is a weekly summer meal program designed for children aged 5-18. Weekly distribution begins Saturday, June 5th and ends on Saturday, July 31st (nine Saturdays). The meals provided during this summer program are intended to replace breakfast and lunch provided throughout the school year by the free/reduced lunch program.


If you are a current Metrocrest pantry client, this six digit number is found on the business card you present to pantry staff each week.

You are not eligible for this program.

Sack Summer Hunger is a summer meal program designed for children aged 5-18.



Applicant Information






























Employment Information





XX.XX


$
*Farmers and self-employed persons may report NET income (the amount after business expense).


Household Members
Please list all persons living in the household whether related or not.













Disclaimer & Signature

By completing this application, I certify that my family would like to participate in the Metrocrest Services 2021 Sack Summer Hunger Program. I understand that if my child is allergic to any products, it is my responsibility to prevent him/her from eating those products. In accepting assistance through Metrocrest Services, I give consent for this declaration to be correlated with all participating agencies in order to assure the most efficient use of available funds and delivery of food. I also agree to provide identity, residency, and proof of income information when requested to verify that my family qualifies for this program.


Sack Summer Hunger program participants must meet USDA guidelines for the The Emergency Food
Assistance Program (TEFAP) and must complete the sections below, pursuant to federal law:

By signing below, I certify that:
  1. I am a member of the household living at the address provided in the Applicant/Parent Information section and that, on behalf of the household, I apply for USDA foods that are distributed through The Emergency Food Assistance Program;
  2. All information provided to the agency determining my household’s eligibility is, to the best of my knowledge and belief, true and correct; and
  3. If applicable, the information provided by the household’s “Authorized Representative” (as named below or as authorized separately) is also, to the best of my knowledge and belief, true and correct.

Signed on

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: https://www.usda.gov/oascr/filing-program-discrimination-complaint-usda-customer and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: 1) mail: U.S. Department of Agriculture/Office of the Assistant Secretary for Civil Rights/1400 Independence Avenue, SW/Washington, D.C. 20250-9410; 2) fax: (202) 690-7442; or 3) email: program.intake@usda.gov

This institution is an equal opportunity provider.