Pantry Packs Program Partnership Application

Transcription

1 Pantry Packs Program Partnership Application Pantry Packs Program Location Information 1. School/Site Name 2. Grade Levels 3. School/Site Address 4. County 5. City/State/Zip Code 6. Phone Number 7. Principal/Director s Name 8. Do you store the Pantry Packs at this location? YES NO If no, answer #9 9. Storage Address (include city & state) School /Site Specific Questions Would you like to receive Box Tops? Would you like to receive Labels for Education? Yes No Yes No Day and time of the week Pantry Packs will be distributed to the students: 4. How many 8 th graders are enrolled in the Pantry Packs Program? What High School(s) does your Middle School feed into? Pantry Packs Program Contacts Primary Pantry Packs Contact Secondary Pantry Packs Contact 1. Name 1. Name 2. Title 2. Title 3. Address 3. Address 4. Responsible for submitting monthly reports? Yes No 5. What days during the week are not at the location where your food is stored? 4. Responsible for submitting monthly reports? Yes No 5. What days during the week are not at the location where your food is stored? Page 1

2 Pantry Packs Program Partnership Agreement School/Site Name: Pantry Packs Program Partner AGREES TO: (Please initial) 1. Identify children that are chronically hungry to participate in the Pantry Packs Program. 2. Use school records to identify food allergies children participating in the Pantry Packs Program may have (peanuts, milk, etc.) and flag their name so those items are not distributed to them. 3. Distribute foods free of charge based on nutritional recommendations through Feeding America and provide Pantry Packs a minimum of once a month while the program is in operation. 4. Distribute the Pantry Packs to participants in accordance with the pre-determined schedule discreetly and in a safe environment. 5. Identify individuals to be the primary/secondary contact for the Pantry Packs Program. 6. Inform GHFB in writing of any changes in program personnel and/or number of children being served. 7. Communicate problems and requests to Golden Harvest Food Bank in a timely manner. 8. Ensure staff and volunteers with direct repetitive contact with children pass a national background check. 9. Ensure at least one representative receive food safety training, such as ServSafe Food Handler for Food Banking developed by Feeding America and the National Restaurant Association, or an equivalent training. 10. Keep accurate records and submit reports by the 5 th of the month. 11. Have a working that can be accessed regularly. 12. The safe and proper handling of product that conforms to all Federal, state and local regulations. 13. If your program stores food overnight, the program will allow Golden Harvest Food Bank to monitor the food distribution site operations regularly. 14. Willingness to abide by the policies, procedures, applicable federal and local statutes, ordinances and regulations and record keeping requirements of Golden Harvest Food Bank. 15. Receive deliveries on the designated days and have staff, volunteers or custodians available to store the Pantry Packs in its appropriate storage area. Golden Harvest Food Bank AGREES TO: Appoint a primary contact for the program to provide administrative oversight and leadership. Identify and procure staple food items and/or supplies necessary for the operation of the program. Provide or coordinate training opportunities for program staff and volunteers as appropriate. Page 2

3 Ensure that program partners meet national and local program objectives through periodic site visits at least once a year during designated hours of operation. General Provisions THE terms of this agreement are understood and agreed upon by Golden Harvest Food Bank (GHFB), a member of the Feeding America national network of food banks, and its Pantry Packs Program partner school/site listed. By signing this agreement, both parties acknowledge their respective duties and responsibilities related to the administration of the Pantry Packs Program This Agreement may be terminated at will by either party with written notice delivered to either. Upon termination of this agreement, the Program Partner will return any equipment, materials and/or food provided by Golden Harvest Food Bank for the program within 30 days of termination date. Discrimination Statement Staff or volunteers of the program will not engage in discrimination, in the provision of service, against any person because of race, color, citizenship, religion, gender, national origin, ancestry, age, marital status, disability, sexual orientation including gender identity or expression, unfavorable discharge from the military or status as a protected veteran. Signatures The Program s authorized representative s signature below confirms that the participating school/site is accepting and agrees to abide by all terms of this agreement. The terms of this agreement shall be for the school year. School Principal/Program Director Signature School/Site Pantry Packs Program Coordinator Signature Kimberly Jackson Golden Harvest Food Bank Representative Signature Page 3

4 NATIONAL BACKGROUND CHECK VERIFICATION By signing this form the participating school acknowledges that it understands and agrees to the National Background Search Policy of Golden Harvest Food Bank. Further, The Pantry Packs Program verifies that all individuals who participate in the Pantry Packs Program who have direct repetitive contact with the children are listed here, and have undergone, and passed, a National Background Search as described on the info page. The participating school is required to submit this form when becoming a partner of Golden Harvest Food Bank and each time a new staff or volunteer with direct repetitive contact with students joins the program or a minimum of once every year. School/Site Name: School\Site Pantry Packs Program Representative Name (Print) School/Site Pantry Packs Program Representative Signature Please list the names below of those who participate in the Pantry Packs Program at your location Program Staff/Volunteer Name (Print) Staff Volunteer Page 4

5 PANTRY PACKS PROGRAM FOOD SAFETY QUIZ Please write your answer in the response area for each question. Questions 1. If you have a cut or wound on your hand, it is ok to still pass out Pantry Packs without a glove? 2. Storage areas should be checked every 3 months for signs of pests? 3. I do not need to inspect my boxes when it is delivered? 4. Food should be stored at least 6 inches from the floor? 5. Food can be passed out to students without a permission form completed by a parent? 6. How should you label food for storage? Responses 7. What should you do with damaged items? 8. How can you deny pest entry into your storage area? 9. If you are ever absent, is someone else available to pass out Pantry Packs that is also aware of food safety? Page 5

6 PANTRY PACKS PROGRAM FOOD SAFETY TRAINING School/Site Name: County: How did you receive Food Safety Training? In-Person/Web Training or PowerPoint/Online After completing Food Safety Training, complete the quiz and submit along with this signed Food Safety form. Quiz can be found on page 5 of the application. Some form of food safety training to at least one representative from each site/school is required annually. If applicable: If agencies utilize food provided by the member to make meals, their key food service program staff are required to meet local commercial food safety standards. (Serv Safe Certification). The above named school/site has received Pantry Packs Food Safety Training. Training was provided by a Golden Harvest Food Bank Outreach Representative in person, online or through web training/powerpoint. This training session covered the following topics: Training Purpose/Volunteers Personal Hygiene / Proper Hand Washing Preventing Contamination Temperature Control / Pest Control Receiving, Storing and Delivering Pantry Packs Damaged Product Please contact the Child Hunger Programs Coordinator with any questions regarding food safety. Follow-up training will also be conducted during your annual site visit. Signature: : Signature: : Signature: : Signature: : GHFB Rep: Kimberly Jackson : Page 6