Appendix I4 Parent Info Insert

OMB Control No.:0584-NEW

Expiration Date: xx/xx/xxxx

Attachment I4 Parent Info Insert

Summer Food Service Program Participant Characteristics Study

Participant Contact Information

Instructions:

Please complete the form below. When you have finished, please either e-mail the information to [email protected], fax it to 301-306-1197, or mail it back in the pre-addressed envelope provided.

School District:
Name (print):
Home Address:
Phone: ( )	E-mail:
Alternate Phone: ( )
Convenient times to be contacted Monday through Friday (check all that apply):
9:00AM – 10:00AM	2:00PM – 3:00PM
10:00AM – 11:00AM	3:00PM – 4:00PM
Noon – 1:00PM	5:00PM – 6:00PM
1:00PM – 2:00PM	6:00PM – 7:00PM

Will your child(ren) receive meals at any of the following sites this summer?

<List of local sites>

Additional information you would like to provide (please write below):

Public reporting burden for this collection of information is estimated to average [insert 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 Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.