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Greater Chicago Food Depository Kids Cafe Application

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Greater Chicago Food Depository Kids Cafe Application Powered By Docstoc
					                   Greater Chicago Food Depository
                        Kids Cafe Application
     Please answer all questions and attach additional sheets if necessary. If your
   organization operates more than one site, please include site specific information.

                                 Agency Information:

Agency Name: _________________________________________________________

Contact Person: ________________________________________________________

Title: _________________________________________________________________

Alternate Contact: ______________________________________________________

Title: _________________________________________________________________

Mailing Address:                  Site Address:                     Billing Address:




Phone: _________________________ Emergency Phone: ______________________

Fax number: _____________________ E-mail: _______________________________

Website: ______________________________________________________________

Is your agency already a member of the Greater Chicago Food Depository?

Yes    No

If “Yes,” what is your agency code number? __________________________________




                                   Kids Cafe Application
                                        Page 1 of 9
What is your agency’s mission statement?




How long has your agency been open? ______________________________________

                    After-school/Summer Program Information:

How long has your organization operated an after-school program?




Please describe the goals and objectives of your after-school program including your
target population:




                                  Kids Cafe Application
                                       Page 2 of 9
How do you evaluate your program?




Are families required to belong to an organization in order for their children to
participate? Yes      No
If “Yes,” please specify:




How do families know about your program?




What intake procedures do you have for participants? (Please attach sample
registration forms, if available.)




Do you charge any fees for children to participate? Yes       No
If “Yes,” please describe:




                                    Kids Cafe Application
                                         Page 3 of 9
Does your program operate: After-school only          or After-school and summer       ?

What are the days and hours of your after-school and summer program?

After-school:                                                Summer (if applicable):

Monday:         _______ to _______                 Monday:         _______ to _______

Tuesday:        _______ to _______                 Tuesday:        _______ to _______

Wednesday: _______ to _______                      Wednesday: _______ to _______

Thursday:       _______ to _______                 Thursday:       _______ to _______

Friday:         _______ to _______                 Friday:         _______ to _______

What is the age range of children in the program? _______ to _______

What is your daily average attendance? _______

Please describe a “typical day” scenario:




How many paid staff work with your after-school program?

Full time: _______ Part time: _______

What are their roles within your program and how do you prescreen your staff? (Do you
use criminal background checks etc?)




                                     Kids Cafe Application
                                          Page 4 of 9
How many volunteers work with your after-school program?

Regular: _______ Occasional: _______

What are their roles with in the program?




As a Kids Cafe you will need to conduct weekly nutrition education activities. Do you
currently have a nutrition education component of your program? Yes         No
If “Yes,” please describe:




                                   Meal Service:
What days of the week would you like to serve meals provided by the Greater Chicago
Food Depository?
(You must serve these meals at least twice a week but you may serve them up to five days a week. If
you so desire, you can serve GCFD meals twice a week, and for the other days, prepare your own meals
or snacks with food you purchase from our warehouse and other sources.)

        Monday           Tuesday          Wednesday             Thursday         Friday

What time would you like to serve the meals? (ex: 3:30-4:15) ________ to ________

Meals are available for the participating children only. How many meals per serving day
would you require? _______




                                        Kids Cafe Application
                                             Page 5 of 9
Your site would need to have the capability to store, heat and serve the meals from the
Greater Chicago Food Depository. Do you currently have the following things?
(R= required, O= optional/recommended)
Item:                                           Yes or No and quantity (if applicable):

1. Refrigerator (R)                                                    _______________

2. Thermometer to measure refrigerator temp. (R)                       _______________

3. Stove (R)                                                           _______________

4. Bimetallic Stem Thermometer to test food temp. (R)                  _______________

5. ¼ Cup serving spoon (R)                                             _______________

6. ½ Cup serving spoon (R)                                             _______________

7. Plates for every day (paper is fine) (R)                            _______________

8. Silverware for every day (plastic is fine) (R)                      _______________

9. Napkins (R)                                                         _______________

10. Three compartment sink (R)*                                        _______________

11. Kitchen cleaning supplies (R)                                      _______________

12. Cafeteria style trays (O)                                          _______________

13. Steam (buffet) table to hold food at a hot temperature (O) _____________

14. Countertop food warmer or hot food holder (O)                      _______________

15. Convection oven to heat food more rapidly (O) **                   _______________

16. Condiments like ketchup and hot sauce (O)                          _______________

17. Stock pot to heat boil-in-bag foods (O)                            _______________

18. Cart to transport food from kitchen to serving area (O)            _______________
* If your kitchen doesn’t have a three-compartment sink, you would have to use separate buckets or
basins in order to wash, rinse and sanitize serving utensils in accordance with the three step system
required by the Greater Chicago Food Depository.
** Convection ovens are more expensive to purchase and service than conventional ovens but can heat
food 20%-30% faster. Conventional ovens work fine to reheat meals from the Greater Chicago Food
Depository.
Note: If you are awarded Kids Cafe start-up funding, you could use it to purchase these
items.

                                         Kids Cafe Application
                                              Page 6 of 9
Before your program can receive meals from the Greater Chicago Food Depository, you
must have two certified food handlers on site and you must submit copies of the
licenses. Sites in Chicago need City of Chicago licenses and those outside of the city
need State of Illinois licenses.*

How many Certified Food Handlers do you currently have on your staff? ____________


Name of Certified Food Handler: ___________________________________________

License Expiration date: ___________________

State of Illinois License                City of Chicago License


Name of Certified Food Handler: ___________________________________________

License Expiration date: ___________________

State of Illinois License                City of Chicago License


Has your building been inspected by the Bureau of Fire Prevention or a fire department
inspector in the last year? Yes   No

Has your building been inspected by the local Public Health Department in the last
year? Yes      No

If “Yes,” please submit a copy of the inspections with your application.
If ‘No,” please note that your site must have the inspections before your program can
begin to receive meals. ** (N/A for sites in public schools.)


What is the name and address of the public school located nearest to your site?
______________________________________________________________________

______________________________________________________________________


*We offer the “Food Service Sanitation” certification class at a reduced rate through our Pantry University
program. To enroll in the class, please submit this application and then contact Pantry University through
our main line, 773-247-3663. You cannot enroll until your application has been submitted.

**Contact your local fire department and local public health department or call “311” in the city of Chicago
to find out how to schedule an inspection. Request that the inspector leave you a copy of the inspection
because if there are no findings, they may not provide you a copy.




                                           Kids Cafe Application
                                                Page 7 of 9
Is there a pest control plan in place at your site? Yes     No

If “Yes:” What is the name of your extermination company? ______________________

What is the date of your last extermination? ___________________________________

How often does the company visit your site? __________________________________

If “No,” please note that you must have a plan in place before your program can begin
to receive meals.


                              Nutrition Program Evaluation:
The Greater Chicago Food Depository has an outcome evaluation component for the
Nutrition Education programs of the Kids Cafes. Participation in the evaluation process
is required in order to receive meals from the Greater Chicago Food Depository.

Would you be willing to complete a one page report form monthly regarding what
Nutrition Education subjects your program has covered? Yes     No




                                    Kids Cafe Application
                                         Page 8 of 9
                                    Attachments
Please submit the following attachments with your application and check the boxes to
indicate that they are included:

   Your Federal 501 c 3 Tax Exempt Determination letter
   A copy of your agency’s budget
   A copy of the program budget for the after-school program
   A list of members of your board of directors and the business or professional
affiliation of each member
   Two letters of support- if your program operates out of a school, one letter must be
from the principal
   Sample participant registration forms if available
   A brochure or annual report if available

Prior to being able to receive meals from the Greater Chicago Food Depository:
You must submit copies of two city (if operating in Chicago) or State (if operating
outside Chicago) food sanitation licenses. If you do not yet have two licenses, you are
encouraged to submit your application while you are in the process of acquiring these
licenses.*
    1.    Check here if license is attached with application
    2.    Check here if second license is attached with application
*We offer the “Food Service Sanitation” certification class at a reduced rate through our Pantry University
program. To enroll in the class, please submit this application and then contact Pantry University through
our main line, 773-247-3663. You cannot enroll until your application has been submitted.

You must submit a copy of a fire inspection conducted by the Bureau of Fire Prevention
or the local fire department and a public health inspection conducted by the local public
health department (N/A for sites in public schools). If your building has not been
inspected in the last year or you do not have a copy of the inspection, you are
encouraged to submit your application while you are in the process of obtaining the
inspection report.*
      Check here if report is attached with application

*Contact your local fire department and local public health department or call “311” in the city of Chicago
to find out how to schedule an inspection. Request that the inspector leave you a copy of the inspection
because if there are no findings, they may not provide you a copy



Date of Submission: _____________________________________________________

Please return the completed application to:

                                 Greater Chicago Food Depository
                                      Attn: Kenisha Robinson
                                     4100 W. Ann Lurie Place
                                         Chicago, IL 60632

Incomplete or faxed applications will not be considered. Applications will be evaluated as they are
received. If you have any questions or concerns while completing this application, please do not hesitate
to call Kenisha Robinson at (773) 843-2651 or e-mail at krobinson@gcfd.org
                                           Kids Cafe Application
                                                Page 9 of 9

				
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