Consent for Disclosure
Sharing Information With Other Programs

Dear Parent/Guardian:

You do not have to complete this section of the form to get reduced price or free Child Nutrition Program benefits for your children. If you do not sign the Consent of Disclosure, it will not affect eligibility for or participation in the Child Nutrition Programs.

To save you time and effort, information about your children's eligibility for reduced price or free Child Nutrition Program benefits may be shared with other programs for which your children may qualify. For the program listed below, we must have your permission to share your information.

Yes, I DO want school officials to use the information provided above to determine eligibility to receive fee waivers for the following school fees I have checked below.

List all students, school, and grade below.

By entering your name below, you are signing this disclosure electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Consent for Disclosure.

*Parent/Guardian Signature      *REQUIRED      Date:

                       Address:    

If you click "submit" and do not get a THANK YOU screen the form did not successfully process, please try again or call Information Services at 316-554-2203.

For more information, you may call or email:

Gina Lee, Director of Nutrition Services
Phone: 316-554-2219 Email: ginalee@usd261.com
Address: Food Services, 132 Stewart Door #15, Haysville, KS 67060

Non-Discrimination Statement is included and formatted accordingly, as follows:

In accordance with Federal 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 the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may 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: https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint, and at 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 Assistant Secretary for Civil Rights
     1400 Independence Avenue, SW
     Washington, D.C. 20250-9410;

(2) Fax: (202) 690-7442; or

(3) Email: program.intake@usda.gov.