Child Nutrition Supplemental Application
Child Information
Full Name
Date of Birth
Gender
Male
Female
Other
School / Childcare Name
Parent/Guardian Information
Parent/Guardian Full Name
Relationship to Child
Phone Number
Email Address
Home Address
Household & Income Information
Number of People in Household
Income Frequency
Weekly
Bi-Weekly
Monthly
Annually
Total Household Income
Dietary/Medical Information
Food Allergies
Medical Conditions Affecting Diet
Special Dietary Requirements
Authorization & Agreement
I certify that the above information is true and correct.
Signature
Date