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):

Site Supervisor:

Contact Title:

Contact Phone Number:  Contact Email:

Assistant Site Supervisor:

Site Supervisor Title:

Site Phone Number: Site Email Address:

Please select whether you will serve meals indoors or outdoors.

Indoors
Outdoors

Dates of Operation (SFSP starts the day after the last day of Fairfax County Public Schools.  The program ends the Friday prior to school being back in session.)

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:  


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

What is your type of site?  Please make a selectionFaith Based OrganizationNon Profit Organization (501C3)Apartment ComplexFairfax County AgencyFairfax County Park Authority
 

Other:

Type of activity at your site:  Please make a selectionEducationRecreationCamp

Other:

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