SCHOOL INFORMATION for School Year (Please Print)

STUDENT NUTRITION PROGRAM (SNP) GRANT APPLICATION

 All sections of this form must be completed for Algoma Family Services to consider your application.  Previously funded programs must submit all reports before repeat funding can be granted.

SCHOOL INFORMATION for school year (Please print) School: School Board: Address (street address, city and postal code) : Phone: Fax: Principal: Principal email: Secretary: School Lead Contact/Coordinator: Lead Phone: Lead Email: School Financial Contact: Financial email: SSM Central/East Algoma District: North Algoma Hornepayne Language /Correspondence Preference: English French Type of school: Elementary Secondary Alternative First Nation: Yes No School Enrolment:

Group Funding: AFS Student Nutrition Program continues to research grant opportunities to support school-based nutrition programs. If an opportunity arises, would you like to be included in the group application? Yes No. If yes, staff will consult with you as we prepare the application.

SNP Office Use Only

Date Application Received: ______Document Uploaded: ______Grant Amount Requested: ______School Funding Designation: ______PROGRAMType of Program OFFERED Funded: ______Equipment Grant Funding: ______1 Meal Program (i. e. breakfast, morning meal, or Snack Program contains at least one serving lunch) contains at least one serving from a from a minimum of two food groups of Canada’s minimum of three out of the four food groups of Food Guide with at least one serving from the Canada’s Food Guide with at least one serving vegetables and fruit food group. from the milk and alternatives food group.

Please select the type of program that best meets the nutritional needs of your school. Breakfast (offered prior to the start of the school day) AM Snack

Morning Meal (offered in the first part of the school day) PM Snack Lunch

Demographics: If the demographics of your school population or your community have changed or you have not filled out demographic information in the last 2 years please complete Appendix I of this application. Appendix I completed: Yes No BUDGET A. What is the anticipated start date of your

program? B. What is the anticipated end date of your

program? C. How many weeks will you offer the program? (maximum 38 weeks) D. How many days per week will you offer the

program? (2, 3, 4, or 5) E. Estimate the number of students that will

access your program daily. F. Average Cost per Meal Breakfast/morning meal =$2.00/day AM/PM Snack=$1.25, Lunch=$3.00/day G. Total Food Costs: (C x D x E x F)

Equipment: Should your school require equipment for the upcoming school year, please complete Appendix II of this application. Appendix II completed: Yes No

PROGRAM REVENUE SUMMARY PROGRAM EXPENSE SUMMARY Grants (other than funds received from $ Food (G.) $ MCYS Student Nutrition Program) Fundraising $ Equipment (refrigerator, toaster, $ etc.) Student/Parent Donations $ Supplies (forks, hairnets, dish soap, $ baggies, etc.) Other Donations $ Other $ TOTAL REVENUE $ TOTAL EXPENSES $

Based on the above information, please enter the grant amount you are requesting. $

2 School Name:

Program Offered: _ ____

SAMPLE MENU YOUR MENU

Breakfast Snack Lunch Food Group Monday Tuesday Wednesday Thursday Friday Sample Sample Sample ½ cup ½ cup (125ml) cucumber Vegetables 1 small 100% and bell and fruit apple unsweetened pepper juice strips 1 whole Grain 1 slice whole wheat Products wheat bread tortilla 50g (1 ½ oz.) ¾ cup (175g) Milk and 1 cup mozzarella low fat Alternatives (250ml) milk cubes yogurt Meat and 75g (2 ½ oz.) 1 boiled egg Alternatives light tuna 1 tbsp. Other foods (15ml) light mayonnaise

Do you require Safe Food Handling Training for any staff or volunteers? Yes No If yes, how many?

3 Declaration:

I, ______am the authority for this organization and agree to:

Read the SNP Eligibility Requirements and do everything possible to meet it. http://www.algomafamilyservices.org/index.php?g=3,24,63

Serve nutritious food that meets the Ministry of Children and Youth Services SNP Nutrition Guidelines, July 2008. Efforts will be made to serve foods that are inclusive and sensitive to the faiths and cultures our students. http://www.children.gov.on.ca/htdocs/English/topics/schoolsnacks/nutrition_guidelines.aspx

Maintain Food Safety Standards in accordance with the Health Protection and Promotion Act for Food Premises, R.R.O. 1990, REGULATION 562. http://www.e-laws.gov.on.ca/html/regs/english/elaws_regs_900562_e.htm

Have at least one person on-site certified in the last five years in Food Safety. Staff and volunteers will be encouraged to attend Food Handler Training as opportunities arise.

Offer a program that is non-stigmatizing and open to all students regardless of their ability to pay.

Allow the program to be visited by one or all of the following: funders, public health dietitian and/or inspector, school board representative and other community stakeholders.

Submit activity and financial reports every month, and provide additional information as requested by Algoma Family Services Student Nutrition Program.

Let SNP share program information, on an as needed basis, with representatives of school boards, SNP Advisory Coalition, funders, public health and other community stakeholders,

AND confirm that the information in this grant application is true and correct.

Signature

FORMTEXT FORMTEXT Date

4 Appendix I

Demographic Information

Please tell us more about the population of your school and the surrounding community: i.e. proportion of newcomers, large ethnic populations, socioeconomic status including new/lost jobs, remote/urban community challenges, etc.

5 Appendix II

One-time equipment grants, when available, will be granted to support start-up and maintenance costs for your breakfast, morning meal, lunch and/or snack program. Equipment requests will be awarded as follows:

1) Pending funding availability; 2) As it relates to the service delivery of your SNP program giving priority to items that address safe food handling practices.

Please identify your equipment needs below:

Item Quantity Description Cost Total (incl. tax) i.e. Fridge 1 GE All Fridge 2316 850.00 960.50 i.e. Stock Pot 2 1-10qt, 1-16qt 150.00 169.50 Fridge Freezer-chest Freezer-upright Stove Dishwasher Cupboards Counter Sink(s)(double, triple, hand) Toaster-rotisserie Toaster-four slice Grill/griddle Microwave Blender Kettle Pots and Pans: Stock Pot(10,12,16,20qt) Braizer (Dutch oven-8,15,20qt) Sauce Pan (2,4…10qt) Baking Tins Utility Cart Storage Bins/ containers/platters Cutting Boards Plates

6 Item Quantity Description Cost Total (incl. tax) Cups Bowls Silverware Knives (utility, paring…) Milk /juice containers Peelers/cutters (vegetable, cheese, fruit) Can Opener Serving Tongs Mixing Bowls Mixing spoons, spatulas, lifters Oven mitts

If at any time your school ceases to provide a Student Nutrition Program, please contact Algoma Family Services Student Nutrition Program at 705-945-5050 x 2312 to arrange to have your equipment and supplies redistributed to other schools in need.