Parent - Notice of Decline

Notice of Decline
You received an email with your eligibility determination (Free, Reduced, or Paid) for particpation in the program. If you received a determination indicating that you're eligible for "Reduced" or "Paid" meals, you may choose to decline participation in the program. If you decline, you will be required to provide meals for your child(ren).

To Decline participation in the program, please complete the form below.
Child's Center Name:
Child's Center Name:
Child's Name:*

First NameLast Name
Child's Date of Birth:*

MonthDayYear
Date
I have more than one child enrolled in the CBS Food Program*

YesNo

Acknowledgements:
As a parent/guardian of the child/children listed above, you chose to Decline the CBS Food Program and will furnish all meals to the child(ren).

CBS Food Program requires that any decline of service be submitted on the 20th of the month in order to remove the child(ren) from service for the upcoming month. If you'd like to decline service mid-month, the decline must be submitted by the 10th of the month.
I have read the above information and acknowledge that I decline CBS Food Program meals and will furnish my own meals to my child(ren):*

I Acknowledge and Decline Service
Signature*

Powered by Jotform SignClear
CBS Email:
example@example.com
Should be Empty:

Notice of Decline