Meal Delivery During COVID-19 Request

    Northern Lights Community School Consent
    for Home Meal Delivery during the COVID-19 School Closure

    I give consent to Northern Lights Community School to deliver meals to my home during the COVID-19 school closure. I understand that household contact information may be shared with school staff, volunteer deliverers or private delivery vendors such as bus transportation contractors. I also give consent for meals to be left if no one is home at the time of delivery.

    By signing below you are authorizing the school food authority to share your contact information with a third party vendor (AEOA) for meal delivery.

    Street Address (required)
    City/State/Zip Code (required)

    Home/Cell Phone (required)

    Email

    Number of eligible children in household (required)
    Parent/Guardian Electronic Signature (required)
    Printed Name (required)
    Date (required)

    For more information, you may call Cindy Schroeder at 218-492-4400 or email at cschroeder@nlcschool.org

    Non-discrimination Statement: 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 found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, 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; or (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.

    This institution is an equal opportunity provider.