Hussc 2012

ATTACHMENT C

OMB Control No.: 0584-0524

Expiration Date: 04/30/2013

Team Nutrition School

Enrollment Form

Our Team Nutrition School Leader is:

FIRST NAME _____________________________ LAST NAME __________________________________________

TITLE ___________________________________ SCHOOL’S NAME _____________________________________

TOTAL ENROLLMENT ____________________ GRADES TAUGHT |____________________________________

SCHOOL DISTRICT _______________________ SCHOOL COUNTY ____________________________________

SCHOOL ADDRESS ______________________________________________________________________________________

______________________________________________________________________________________________________

CITY ______________________________________________ STATE _____________________ ZIP CODE _______________

TELEPHONE ( ) ___________________________________ FAX ( ) ____________________________________________

E-MAIL ADDRESS ____________________________________________________________________________________________

Please check one or more of the appropriate grade ranges:

□ P (PRESCHOOL) PRE-K □ E (ELEMENTARY) K-5/6 □ M (MIDDLE) 6/7-8 □ H (HIGH) 9-12

We agree to:

• Support USDA’s Team Nutrition goal and values. • Involve teachers, students, parents, foodservice

• Demonstrate a commitment to help students meet the personnel, and the community in interactive and

Dietary Guidelines for Americans. entertaining nutrition education activities.

• Designate a Team Nutrition School Leader who will • Participate in the National School Lunch Program.

establish a school team. • Demonstrate a well-run Child Nutrition Program.

• Distribute Team Nutrition materials to teachers, • Share successful strategies and programs with

students and parents. other schools.

We certify our school does not have any outstanding overclaims or significant program violations in our school meals programs.

__________________________________________ __________________________________________

SCHOOL PRINCIPAL, PRINTED NAME SCHOOL FOOD SERVICE MANAGER, PRINTED NAME

__________________________________________ __________________________________________

SIGNATURE SIGNATURE

__________________________________________ __________________________________________

E-MAIL E-MAIL

__________________________________________ __________________________________________

DATE DATE

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524).  Do not return the completed form to this address.