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Summer Food Service Program (SFSP) Application

Neighborhood and Community Services

12011 Government Center Parkway, Tenth Floor
Fairfax, VA  22035-1115
Phone 703-324-4600, TTY 711
Fax 703-222-9792

To become a meal site, please fill-out the application below. Neighborhood and Community Services staff will send you an e-mail stating it has received your application. Approval of your application is determined by the United States Department of Agriculture (USDA). If you have any questions, please call 703-324-5330, TTY 711.

Site Name:

Site Address 1:

Site Address 2:

City: County: State: Zip Code:

Site Phone Number: Site Fax:

Delivery entrance number, if applicable (School Sites):

---

Administrative Contact Name:

Contact Title:

Contact Phone Number:  Contact Email:

Site Supervisor Contact Name:

Site Supervisor Title:

Site Phone Number: Site Email Address:

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Would you like to participate as a "meal service" site?
Yes
No
Maybe (Need Additional Information)

Indoor
Outdoor

Dates of Operation (SFSP starts the day after the last day of Fairfax County Public Schools.  The program ends the Friday prior to Labor Day.)

Beginning Date:     End Date:  

Days of Operation (Please check box)

 Monday

 Tuesday

 Wednesday

 Thursday

 Friday

How many Days of the SFSP will you operate?  (Program closed Weekends and July 4th)

June:  

July:   

August:  

September:  

What is the closest Fairfax County Public School to your site?  

What is your type of site?   Please make a selection Faith Based Organization Non Profit Organization (501C3) Apartment Complex Fairfax County Agency Fairfax County Public Schools Fairfax County Park Authority

Other:

Type of activity at your site:   Please make a selection Education Recreation Camp

Other:

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Requested Participation and Meal Times

Breakfast (breakfast is optional)

Earliest Time of Delivery:  

Beginning Serving Time:  

Ending Serving Time:  

Estimated Number of Participation (minimum 15):  

Lunch

Earliest Time of Delivery:  

Beginning Serving Time:  

Ending Serving Time:  

Estimated Number of Participation (minimum 15):  

Do you have a refrigerator to store?
Yes
 No

Reasonable accommodations will be made upon request. 703-360-6088, TTY 711.