HomeMy WebLinkAboutNew SiteSummer Food Service Program
New Site Information
Internal Use Only
I have checked the following sources for
the attached new site (s)
Yes No NIA
Child Care Centers List _ X
CNP Report SFSRP 2032 X,
Closed Charters School List X
Site Manager
USDA National Disqualified List
Online Map (i.e. Map Quest for site
proximity)
X
2010
Internal Use Only
Approved By
Date
Site Number
Number: 04 -
-Agreement
me; City of Miami Parks
and Recreation Department
New Site Name: Henderson Park
Check Site Type: [x_1 Recreation 0 School
El MigrantEj Church ❑ Homeless ❑ Pff
Residential Camp Non -Residential Camp
Care ❑ WSP ❑ CROP ❑ Upward Bound
Street Address: 971 N. w. 2 Street
Ci Miami, Florida
Zi 33130
per: 305/ 575-5264
E-mail: gkitchen@vi.miami.fl.us
Today's Date: 0 2/ 2 4/ 10
NameMitle of Person Adding Site: Mauro
Bermudez
How will you determine eligibility? X Survey 3 Census Tract Other (specify):
Name of qualifying school:
NOTE: This form can be faxed or emailed to your Program Representative. If you choose to
submit this form to our office via e-mail, you will receive an e-mail confirmation that your form has
been received and is being processed.
REMINDER: Once your new site name has been added to the system a program representative will
email you the site number. Once verified by you, you can complete the site application process for
the new site(s). This site application must be approved by the State agency prior to meals
served and claimed at this site. If you should have any questions, please contact your program
representative at 1/800-504-6609 or via e-mail.
Submit form Via fax (850) 245-9276 or Via a -mail:
Julie.Wilkinson@fldoe.org Region 1
Wendy.Rude@fIdoe.org Region 2
Lisbeth.Rytiewski@fldoe.org Region 3
Lori.Ciszak@fldoe.ora Region 4
Awilda.Font@fldoe.ora Region 5
Craig.Clemmer@fldoe.oro Region 6
Barry.Barnett@fldoe.ora Region 7
Lisamarie.Church@fldoe.ora Region 8
Brenda.bekle@fldoe.org Region 9
SFSP-A15 Revised
4 19 ionrnnnn