West Virginia Department of Education
Office of Child Nutrition
NSLP-Snack Site Application
2004-2005
County/Sponsor
Address
Site Name
Address
Approved/
Denied
NSLP
Snack
Traditional
(T)
NSLP
Snack
At-Risk
(T)
* If At-Risk
Enter
October
% Needy
Having Educational
or Enrichment
Activity?
(Yes/No)
1.
Estimated
Enrollment
Ages or
Grades
Participating
Contact Person
and Phone
Press Shift +
enter to force a
new line
0.00%
2.
0.00%
3.
0.00%
4.
0.00%
5.
0.00%
I agree to all the terms of the Agreement Addendum for participation in the National School Lunch Program (NSLP)-Snacks, and certify that the above information
is correct to the best of my knowledge.
Sponsoring Agency Authorized Official Signature/Title
Approving WVDE Signature/Title
Print Name
Date
Print Name
Date
* Sites that are applying for At-Risk status based on feeder schools’ percentage needy criteria must list below each such site and the corresponding
feeder school(s). Prior approval from the West Virginia Department of Education, Office of Child Nutrition is required:
WVDE-ADM-11
Rev. 5/9/04
Site
Feeder School(s)
Site
Feeder School(s)
Site
Feeder School(s)
TS/S/003msw