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Application

Ohio Summer Food Service Program For Children
Income Eligibility Application For Camps and Enrolled Site


Dear Parent or Guardian:

Our organization serves nutritious free meals as part of the federally funded Summer Food Service Program for Children (SFSP). Children are defined by the SFSP as being 18 years of age and under or persons over 18 who are determined by a state or local public educational agency to be mentally or physically disability. In order to be eligible for the SFSP, we must document the number of enrolled children with household incomes less than or equal to the SFSP family size/income guidelines. With your cooperation, we can qualify for federal reimbursement and keep costs to you at a minimum. Please complete and return this form.

RACIAL/ETHNIC CATEGORY:

You are not required to answer this question. If you choose, please check one or more of the following racial or ethnic identities:

Ethnic Identities:
(not required)
Ethnic Identities
NON-DISCRIMINATION: In accordance with Federal Law and U.S. Department of Agriculture policy, This institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.


REDUCED INCOME ELIGIBILITY GUIDELINES – 185%

Guidelines to be effective from July 1, 2017 to June 30, 2018
Households with incomes less than or equal to the reduced price values below are eligible for free or reduced-price meal benefits.
Household Size Yearly Income Monthly Income Twice Per Month Income Every Two Weeks Income Weekly Income
1 22,311 1,860 930 859 430
2 30,044 2,504 1.252 1,156 578
3 37,777 3,149 1,575 1,453 727
4 45,510 3,793 1,897 1,751 876
5 53,243 4,437 2,219 2,048 1,024
6 60,976 5,082 2,541 2,346 1,173
7 68,709 5,726 2,863 2,643 1,322
8 76,442 6,371 3,186 2,941 1,471
For each additional family member, add 7,733 645 323 298 149
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Please enter all pay periods and gross pay per income source.
(his income, her income, alimony received, child support received, pensions, retirement, welfare, social security, and any other source)

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Privacy Act Statement: Section 9 of the National School Lunch Act (NSLA) requires that, unless your child’s food stamp or OWF case number is provided, you must include the social security number of the adult household member signing the application or indicate that the household member does not have a social security number. Provision of a social security number is not mandatory, but if a social security number is not given or an indication is not made that the signer does not have such a number, the application cannot be approved. This notice must be brought to the attention of the household member whose social security number is disclosed. The social security number may be used to identify the household member in carrying out efforts to verify the correctness of information stated on the application or shared with other persons directly connected with the administration or enforcement of the program under the NSLA or Child Nutrition Act of 1966 to determine program eligibility. These verification efforts may be carried out through program reviews, audits, and investigations and may include contacting employers to determine income, contacting a food stamp or welfare office to determine current certification for receipt of food stamps or OWF benefits, contacting the state employment security office to determine the amount of benefits received and checking the documentation produced by household members to prove the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims or legal action if incorrect information is reported.
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Children
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Child #1
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Sorry, before/after care is full.
Add Another Child
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Parents, Guardians, Emergency Contacts

Parent/Guardian

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Emergency Contact #1

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Emergency Contact #2

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Income Eligibility

Ohio Summer Food Service Program-2018 Income Eligibility Application

Attachment 10

INSTRUCTIONS: Part 1 of this form is to be used only for children receiving OWF, Ohio Works First (was formerly TANF and AFDC) or for children living in a household receiving Food Stamp benefits. Part 2 is only for children not receiving Food Stamp benefits or OWF benefits. Fill in the part which addresses your situation. An adult signature is needed when completing both Part 1 or 2. If you need more space, use a separate piece of paper. (* Asterisk items must be filled in for each part you complete.)
* PRINT CHILD INFORMATION WHEN COMPLETING EITHER PART 1 OR PART 2: Enter ONLY name of those children who will be participating in the Summer Food Service Program.

PART 1 - FOR CHILDREN RECEIVING FOOD STAMPS OR OHIO WORKS FIRST (OWF)

Please enter one of these three identification numbers
(10-12 digit number)
(Food Distribution Program on Indian Reservations)
PENALTIES FOR MISREPRESENTATION: I certify that all of the above information is true and correct and that the food stamp and OWF numbers are correctly reported. I understand that this information is being given for receipt of federal funds; that program officials may verify the information on the application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws.

Authorize Part 1
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Medical Info & Waiver

MEDICAL INFORMATION AND WAIVER

EVENT: Vineyard Summer Program

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In case of an emergency contact:

Emergency Authorization Signature


I, the parent/legal guardian of the participant, who is a minor, hereby authorize leaders, team members, supervisors and vehicle drivers as my agent to consent to medical, surgical or dental examination and/or treatment. In case of an emergency, I hereby authorize treatment and/or care of any hospital. If there is an emergency and I cannot be reached please contact:

Emergency Contact #1 (as entered on the Parent, Guardians, Emergency Contacts tab)

Emergency Contact #2 (as entered on the Parent, Guardians, Emergency Contacts tab)

Who is Authorized in My Behalf

I acknowledge that I desire the child(ren) listed below to participate in the 2018 Vineyard Summer Program, June 11, 2018 to July 27, 2018, which takes place at the Vineyard Columbus and Vineyard Community Center. My child's participation in any and all activities is voluntary and I agree to accept the risks of his/her participation, including all risk of personal injury or death.

In consideration for Vineyard Columbus and Vineyard Community Center permitting me to participate in this event and all its activities and to use their facilities and equipment, I agree on behalf of myself and my personal representatives and their successors in interest (all hereafter referred to as “releasers”) to release Vineyard Columbus and Vineyard Community Center, it’s officers, trustees, directors, employees and agents (hereafter referred to as “releasees”) from all liability for any loss or damage and any claim for damages thereafter, on account of injury to my personal or property or death, whether caused by the negligence or releases or otherwise while I am participating in trip activities. I further agree to indemnity release and each of them from loss, liability, damage or cost releases may incur due to my participation and related activities, whether caused by the active or passive negligence or releases or otherwise.

I expressly agree that this release, waiver and indemnity agreement is intended to be broad and inclusive as permitted by the laws of the State of Ohio and that, if any portion of the agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I have carefully read the above release and I know its contents. I am aware that this is a release of liability and I sign this voluntarily.
I do hereby grant and give Vineyard the right to use my photograph or image (or the photograph or image of the participant for whom I am signing) with or without my/our names, both single and in conjunction with other persons or objects for any and all purposes including, but not limited to, private or public presentations, advertising, publicity and promotion relating hereto. I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold Vineyard harmless of and from any and all liability of whatever nature, which may arise out of result of such uses.

I release all officials and professional personnel from any claim whatsoever on account of first aid, treatment or service rendered to me during participation in these activities. This release contains the entire agreement between the parties. The terms of this release are contractual and not a mere recital.

SIGNATURE OF PARENT OR GUARDIAN (IF PARTICIPANT IS A MINOR) CONSENTING TO A MINOR’S PARTICIPATION UNDER THE FOREGOING TERMS AND CONDITIONS:

I understand that I will be enrolled in Vineyard’s text message alert system.

Guardian Signature

Travel Authorization Release

I authorize (list all children's names) :
To travel with VCC Summer on field trips and/or events in a car, rental vehicle, or by public transportation, or by contracted bus company.

Guardian Signature

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Payment
Credit/Debit Cards Accepted:
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CANCELLATION POLICY

FULL REFUND (LESS $50.00 PROCESSING FEE) WILL BE GIVEN FOR CANCELLATIONS RECEIVED BY 5 P.M., FRIDAY, MAY 18. CANCELLATIONS RECEIVED AFTER THEN BUT BEFORE 5 P.M., THURSDAY, MAY 31 WILL RECEIVE 50 percent REFUND (LESS $50 PROCESSING FEE). NO REFUNDS AFTER THURSDAY, MAY 31.

AGREEMENT TO INDEMNIFY, AND NOT SUE, AND RELEASE OF ALL CLAIMS

I desire for myself and/or my child(ren) listed above (collectively, whether one or more, the “Participants”), voluntarily and with full assumption of all risks, to participate in the Vineyard Community Center program(s) described above and all incidental activities (collectively, the “Activity”), and in consideration of your acceptance of this registration, I agree, for myself, the Participants, and my/their respective representatives and successors-in-interest to waive and release Vineyard Community Center and Vineyard Church of Columbus and their respective officers, trustees, directors, employees and agents from all liability for any injury, damage, or loss incurred or suffered by any Participant resulting directly or indirectly from any Participant’s participation in any Activity, including without limitation the provision of any first aid, emergency or other medical attention necessitated by the Participant’s participation in any Activity. I hereby grant and give Vineyard Community Center and Vineyard Church of Columbus the right to use each Participant’s photograph or image with or without my/our names, both single and in conjunction with other persons or objects for any and all purposes, including but not limited to private or public presentations, advertising, publicity and promotion.

PLEASE READ CAREFULLY, BY SIGNING YOU WAIVE CERTAIN LEGAL RIGHTS.

Digital Signature

By signing below, I certify that I have read and agree to the terms and conditions listed on this page. I also affirm that I am the cardholder and have been properly informed that my card will be charged by "Vineyard Community Center" for the total amount of the fees shown above.
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Submit Registration

FACILITY HOURS

THE VINEYARD CHILDHOOD CENTER:

Monday-Friday, 7am-6pm

ALL OTHER VCC PROGRAMS AND SERVICES:

Monday-Friday, 8am-9pm
Saturday, 9am-2pm
Sunday Event Dependant

CHURCH SERVICE:

Times & Locations

PHONE NUMBER:

614.259.5500
Email

PLAYGROUND

MONDAY-FRIDAY:

Reserved for Church Events

SATURDAY:

Open from 9am-1pm for Visitors

RULES:

All children must have a parent or guardian with them at all times while using the playground. Playground climbing/sliding equipment is for use only by children ages 4 - 11.

Call to verify availability: 614.259.5500

LOCATION

Vineyard Community Center Map
Vineyard Community Center
6000 Cooper Rd.
Westerville, OH 43081
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