COM 0140.056 2002-2004 - Laserfiche WebLink

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SFSP-3 1/02 STATE OF HAWAII I. AGREEMENT NUMBER _ DEPARTMENT OF EDUCATION I ~ D ~ -~j OFFICE OF HAWAII CHILD NUTRITION PROGRAMS 2. NAME & MAILING ADDRESS OF APPLICANT/SPONSOR SPONSOR APPLICATION FOR PARTICIPATION CollntV of, Hawaii-Depdrtm~pt,of Parks & SUMMER FOOD SERVICE PROGRAM ec eatl0n- ecrea 10n 1v1S10n 799 Piilani Street, Hilo, HI 96720 INSTRUCTIONS: Complete two copies oC[his application. Submit applicafions with an original form SFSP-4 (Site Information Sheet) for each site and for each TELEPHONE NUMBER ( )(808) 961-8740 eXt 23 session (if more than one is offered) where [he program will be administered by the ~ ,t,~~ QF` _ " , ~ applicant If more space is needed, continue on a plain sheet of paper numbering ) r k each item. Type or print clearly all infornaNon. _ NOTE FOR SPONSORS WHO OPERATED THE SFSP LAST YEAR' The State r 2 rf '""S't?s "7tr ~ t~ l~s _ ~ = r~~t i agency may designate sponsors which have operated some or all of the same sites in 4 ~ bi s : ~ DMIviER~ [he SFSP in [he prior year with no significant deficiencies or operafional problems as ` ' C. u ' 'r t x - "Experienced;' and allow these sponsors to omit certain information from Sponsor t` + kk 1 § ~ t t t t ar-.:' k - and Site application fortis if the information has no[ changed from the previous I k~3~ ~~21+~~ #IN' ` yeas If [he State agency has designated you as an "Experienced" sponsor, you may ' rA ~ ~ ' omit the questions in the shaded blocks on the Sponsor Application and on Site r i ` a > ~yh4ft'~ ~ x ~a s~"' -r`"nu"s;:~"r~' ~ n ` Infoma[ion Sheets for sites which you operated last year if the answers [o these ~4}~~. 'L_ .+ai ~ tzs y a I 6 xu .o. , questions have no[ changed since last year. You must file a complete Site y, ~ I ~ i y~ 'rJrs~I ~y;, s~y`_ t" a,~~~~tg, Information Sheet for any new site which you will operate [his year. I v x r s ~ s ~ z , - r:~x , r,~. Tz'e~~4~t - ~~~.at ~ ~ 3. INTENDED DATES OF FOOD SERVICE PROGRAM ~ ~ ` oPERArtoN Ik~~RT>FtGATtf~7~~;~;TAp~I&D. t; BE June 16 2003 END Jul 25 2003 ' - TOTAL NUMBER OF DAYS OF OPERATION .;i; . 29 4. NAME & TITLE OF AUTHORIZED SPONSOR REPRESENTATIVE WHO ~ ~ ~ - ' WILL SIGN THE AGREEMENT, FORM SFSP-3 - - Patricia Engelhard, Director Department of Parks & Recreation - 6. INDICATE OTHER PROGRAMS IN WHICH THE APPLICANT PARTICIPATES ~ *NONE ~ ~ CHILD & ADULT CARE FOOD PROGRAM ~ ~ NATIONAL SCHOOL LUNCH PROGRAM ~ I SCHOOL BREAKFAST PROGRAM ~ ~ FOOD DISTRIBUTION PROGRAM ~ ~ SPECIAL MILK PROGRAM NOTE: Sites may not participate in [he SFSP and SMP simultaneously 7. HAS THE APPLICANT PARTICIPATED IN THE SUMMER FOOD SERVICE PROGRAM IN PRIOR YEARS? $$YES~ ~ NO IC7yes", has the Stale agency designated you as an "Experienced" sponsor? (If you are unsure, please contact your State agency.) YES ~ ~ NO If'yes'", you may ortut shaded questions on Sponsor Application and on [he Si[e InCornanon Sheets for sites which you operated last year if the responses to the questions have not changed since last year. If "no', state the agreement number, year, and State in which the applicant participated for the most recent period of participafion and complete all sections of the Sponsor Application for Participation and the Site Information Sheet(s) for each site you plan to operate. 8A. DOES THE APPLICANT PROVIDE AN ONGOING, YEAR-ROUND SERVICE TO THE COMMUMTY THAT WOUL,D:~E 9E~tVPD BXTHE SUMMER FOOD SERVICE PROGRAM7'I) YES ~ NO ~ - If `yes", describe the nature df the service; the date it was instituted, and the avetage:number of paid and Yohmtoci^ workers during the shtttioutbs precedmg this application - 86. WAS THE APPLICANT EVER TERMINATED OR DETERMINEDTQ,HAVEBEFN SERIOUSLY DEFfC1ENT'IN,ITS QPERe~TIOpI.OF THE SUMMER FOOD SERVICE PROGRAM OR ANY CHII.D NUTRITION PROGRAM?; ' - - - ' ' I YES- ~I NO Tf `yes"-Please explain below. . ~ . _ _ - - PAGEI OFS