LUNCHROOM APPLICATION FORM & CONTRACT
NAME OF CHILD: _______________________________________________
ROOM #:__________
NAME OF PARENT/GUARDIAN: _______________________________________________________
ADDRESS: __________________________________________________________________________
HOME PHONE NUMBER: _____________________________________________________________
WORK PHONE NUMBER (1): __________________________________________________________
WORK PHONE NUMBER (2): __________________________________________________________
ANY ALLERGIES OR HEALTH CONCERNS:
_____________________________________________________________________________________
_____________________________________________________________________________________
OTHER INFORMATION, COMMENTS:
_____________________________________________________________________________________
_____________________________________________________________________________________
My child(ren) will be staying for lunch on a full time basis.
My child(ren) will be staying for lunch on a part time basis.
 My child(ren) will not stay at school for lunch.
____ Goes home.
____ Attends daycare.
I have reviewed the lunchroom guidelines and expectations with my child(ren) so that they understand
what behaviour is expected of them.
I, _________________________________________ understand that being a member of the
(Student’s name)
Lunch Program is a privilege and that my behaviour over lunch directly affects the atmosphere of all
who participate. It is my responsibility to behave in a respectful manner, not talk back to my supervisors
and ensure that my eating area is left clean. I have read, understand and will comply with the Lunch
Program Expectations.
I am aware that this privilege can, and will be withdrawn for defiance or continuous disruptive
behaviour and it will be my parents(s)/guardian(s) responsibility to make arrangements for me to have
my lunch outside the school program.
_______________________________
Student Signature
______________________________
Date
_______________________________
Signature of Parent/Guardian
***PLEASE
FILL OUT REVERSE SIDE 
Dear Parents/Guardians:
PLEASE KEEP PAGE 1 and RETURN PAGE 2 TO THE SCHOOL.
Re: SCHOOL LUNCH PROGRAM
A break from the building, school routines and a walk in the fresh air are important for children during lunch. We
encourage students to go home or to the sitter’s for lunch, but appreciate that certain family circumstances and
school of choice necessitate a child having to stay for lunch.
Students staying at school for lunch should provide their own substantial, healthy lunch and snack. Please be
sensitive to the time constraints of the lunch hour by sending:
1.
2.
3.
Hot food in thermoses;
Proper utensils (bowls, forks, spoons, etc.)
Microwaves are not provided
Lunch Program Behaviour Expectations
We aim to provide a safe, happy and controlled environment for students to enjoy their lunch and each other.
Please discuss our lunch program behaviour expectations and consequences with your child to ensure the
atmosphere in our lunch areas is safe, appropriate, positive and a pleasant experience for all. Please review, sign
and return to the teacher. Thank you.
Expectations
 Eat quietly at desk or table
 Use an “indoor” voice and practice good manners
 Show respect for supervisors, lunch mates and self
 Report to lunchroom and remain within school boundaries unless the school receives a signed note or a
phone call
 Consume all food indoors (including treats)
 Do not exchange food because of allergies
 Lorelei’s Behaviour and Conduct Policy is pertinent during lunch hour
 Remember that Lorelei is a safe and caring school and treat all others accordingly
Consequences
Students who choose not to co-operate with Lunch program Expectations will receive a warning. If inappropriate
behaviour continues, a record of the behaviour will be documented on an Office Referral. Three referrals will
result in the loss of privilege of lunching with peers for up to one week. The student will eat lunch in another
supervised area and the parent will be informed.
If unacceptable behaviours continue, the student will lose the privilege of staying at school in the Lunch Program.
Students who show improvement in behaviour by not receiving an Office Referral for thirty (30) days will be given
a “clean slate”.
Students who consistently display appropriate behaviours during the lunch program will be recognized through a
Pride Referral. We appreciate students who help create a positive lunch time environment by co-operating with
our lunch program and school expectations.
Please contact me at 456-4488 if you have any questions or concerns.
Sincerely,
Liz Yule
Principal
Lunch Program Schedule
Division 1 and Division 2 students will eat their lunch at opposite times.
Supervisors will be assigned two classrooms adjacent to each other to supervise. There will be one
supervisor for every 2 classrooms.
Division 1
(Grades 1-3)
will eat from 11:33 – 12:00
Division 2
(Grades 4-6)
will eat from 12:00 – 12:25
All students will eat in their own desks in their own classrooms.
Division 1 and Division 2 will be outside for their lunch recess break at opposite times. A bell will ring at
11:55 for the outside students to come in.
Division 2 will be outside from 11:33 – 12:00
All Division 2 students will enter the school through door “D” at 12:00.
All Division 2 students must come inside when the bell rings, and will eat their lunch.
Division 1 will be outside from 12:00 – 12:25
Students who leave the school grounds for lunch to go home, to a day home, or daycare should not
return to school before 12:10. Division 2 students who have left the school over the lunch hour will
come inside when the bell rings to resume classes at 12:25.
LUNCHROOM EXPECTATIONS
Bring a healthy lunch
Listen to the supervisors
Eat enough
Co-operate with the supervisors
Help plan your lunch
Use quiet voices
Take leftovers home
Use positive language
Bring containers and necessary utensils
Keep hands and feet to yourself
Sit at your assigned table
Use appropriate table manners
Recycle
Respect differences
Follow routines
Enter and exit orderly
Keep space clean
Eat only what you bring
Clean up after yourself
LORELEI
LUNCH
PROGRAM
ATTENDANCE IN THE LUNCH PROGRAM REQUIRES PRE-PAYMENT OF FEES
Lunch supervision fees must be paid on time.
Non-Payment of lunch supervision fees will result in withdrawal from the lunch program with
alternate arrangements being the parents responsibility fees are paid in full.
Student Name: __________________________
Room #
______
$150.00 Annual
Cash/ cheque #_____ attached 
$25.00/month/child
Post-dated cheques dated for the 1st of each month
 cheques attached 
$5.00 per day
drop-in attendance
(payment on the day of attendance for drop-in)
Punchcards
available in $20.00 increments, which = 10 stays
(unused money is refundable at the end of the year or applied to
the following year.)