1. LEA Code - Please enter the Local Educational Agency (LEA).
    

2. SFA Name and Address - Enter the sponsoring agency name and address.
    

3.  Please describe the curriculum for after school programs.
    

4. Please enter this information for your contact person.
    

5. Recipient Agency Information:
    

   A.	Recipient Agency Name Physical Address - List the name and physical address of each recipient agency adding a program (No PO boxes please)
   B.	Recipient Agency LEA Code - Indicate the LEA Code for each recipient agency adding the snack provision.
   C.	School Dismissal Time - Indicate the time the regular school day ends at that site.
   D.	School Enrollment - Indicate the number of students enrolled in the regular school curriculum.
   E.	Hours for After School Program - Indicate the beginning and ending times for the after school program.
   F.	Attendance Taken Daily - Indicate yes or no if attendance is taken daily.
   G.	Estimated Enrollment for Snack - Indicate the total enrollment for students who attend the after school program
   H.	Operating Dates - Indicate the start and end dates of the after school program.
   I.	50% or More Free/Reduced Lunches - Does the recipient serve more than 50 % free or reduced lunches - indicate by checking yes or no.

CERTIFICATION - Please print name and title, provide an original signature and date this form. This person should be an SFA employee (not management company employee), authorized by the SFA to act as an official for that agency.

Submit this form in its entirety (keep a copy for your file) along with a copy of your most recent snack menu, to your appropriate regional office. Please click here to locate the regional office for your area.