North Carolina Department of Health and Human Services
Division of Public Health, Women’s & Children’s Health Section,
Nutrition Services Branch, Special Nutrition Programs Annual Application
CHILD AND ADULT CARE FOOD PROGRAM
Child Care Centers, Adult Day Care Centers, Sponsoring Organizations of Centers, Outside School Hours Care Center
AGREEMENT NUMBER: 7093
Family Services Inc. and its daycare and Head Start centers (Sarah Y. Austin, Winston-Salem State University, Kernersville, and Mineral Springs) announce their participation in of the U.S. Department of Agriculture funded Child and Adult Care Food Program. Meals will be available at no separate charge to enrolled participants. The income guidelines for free and reduced price meals by family size are listed on the back of this sheet. Children who are TANF recipients or who are members of SNAP or FDPIR households or are Head Start participants, are automatically eligible to receive free meal benefits. Adult participants who are members of food stamp or FDPIR households or who are SSI or Medicaid participants are automatically eligible to receive free meal benefits.
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: 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 mail to U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410, by fax (202) 690-7442; or email at firstname.lastname@example.org. This institution is an equal opportunity provider.