Child Nutrition Assistance Consent Form
Child Information
Child's Name
Date of Birth
School/Program Name
Parent/Guardian Information
Parent/Guardian Name
Contact Number
Email Address
Consent
I authorize my child to participate in the Child Nutrition Assistance program.
I understand that information provided may be used for eligibility determination and program administration.
Allergies or Special Dietary Needs
Please specify if any:
Parent/Guardian Signature
Date