Family Registration Form for FREE Summer Meals Last Name First Name Legal Guardian Last Name Legal Guardian First Name Address City County Dyer Hardin Lake McNairy Location Phone Number Child # 1 Child # 1 DOB Child # 2 Child # 2 DOB Child # 3 Child # 3 DOB Child # 4 Child # 4 DOB Child # 5 Child # 5 DOB Child # 6 Child # 6 DOB Child # 7 Child # 7 DOB Email Message In accordance with civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (AD-3027) found online at : http://www.ascr.usda.gov/complaint_filing_cust.html and any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) Mail: U.S. Department of Agriculture Office of the Assistance Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410: Fax: (202)690-7442; or Email: [email protected] This institution is an equal opportunity provider. By submitting this registration form, you the parent or legal guardian agree to receive meals from the South West Human Resource Agency Food Services Solutions Program. If you have any questions please call 731-610-1881 Send
