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Southwest Central Kitchen Lunch Menu
Non Congregate Family Registration Form
Cart
Southwest Central Kitchen Lunch Menu
Non Congregate Family Registration Form
We are not acc
epting any more Home Delivery Route applications
You can still register to pick up food at one of our Grab N Go Sites
Cart
Southwest Central Kitchen Lunch Menu
Non Congregate Family Registration Form
Cart
Southwest Central Kitchen Lunch Menu
Non Congregate Family Registration Form
Parent Last Name
Parent First Name
Legal Guardian Last Name
Legal Guardian First Name
Address
County
Benton
Carroll
Chester
Crockett
Decatur
Dickson
Dyer
Fayette
Gibson
Hardeman
Hardin
Haywood
Henderson
Henry
Lake
Lauderdale
Lawrence
Lewis
Madison
McNairy
Obion
Perry
Tipton
Wayne
Weakley
Phone Number
Child #1
DOB 1
Child #2
DOB 2
Child #3
DOB 3
Child #4
DOB 4
Child #5
DOB 5
Child #6
DOB 6
Child #7
DOB 7
Email
Message
In accordance with civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (AD-3027) found online at : http://www.ascr.usda.gov/complaint_filing_cust.html and any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) Mail: U.S. Department of Agriculture Office of the Assistance Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410: Fax: (202)690-7442; or Email: program.intake@usda.gov This institution is an equal opportunity provider. By submitting this registration form, you the parent or legal guardian agree to receive meals from the South West Human Resource Agency Food Services Solutions Program. If you have any questions please call 731-513-7262
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