Healthy Meals & Snacks
NUTRITION
GRANT APPLICATION
Student Nutrition Program
Please ensure that all sections of this form are completed before submitting your application to Algoma
Family Services.
SECTION 1: SCHOOL INFORMATION (Please print)
Date of Request:
School Name:
Principal:
School Board:
School Mailing Address:
City:
Postal Code:
School Enrolment:
Grade Levels:
Phone Number:
Fax Number:
Contact Person for Meal/Snack Program:
Title/Position:
Phone:
Fax:
E-Mail:
Please send your completed application to:
Julie Torcaso
Nutrition Program Associate
Algoma Family Services
205 McNabb Street
Sault Ste. Marie ON P6B 1Y3
Fax: (705) 942-9273
Working in partnership
with
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SECTION 2: UNIVERSALITY
School Nutrition Programs must adopt a universal approach by providing all children and youth the
opportunity to participate regardless of socioeconomic status.
Schools may apply for multiple programs; however, the number of programs funded will be contingent
on funding availability based on the number of schools applying. Please make your selections.
ENERGY BREAK/EAT TO LEARN PROGRAMS
All elementary and secondary schools are eligible for the Energy Break Program or
Eat to Learn Program. Would you like to participate in the 2008/2009 program?



Energy Break/Eat to Learn Programs
Number of operating days
Estimated number of students per day to access the program

Yes
No
5 days per week = 190 school days
4 days per week = 152 school days
3 days per week = 114 school days
2 days per week = 76 school days
Which grocery store do you have a purchasing relationship with?
AFS/SCC is looking to improve the quality of food provided by the Energy Break/Eat
Yes
No
to Learn Programs. Some foods may require refrigeration. Would you be able to
accommodate these items?
Enclosed you will find a copy of the Energy Break Program and Eat to Learn
Yes
No
Program order forms. Your comments and suggestions to improve the quality of food
served would be greatly appreciated. Comments/suggestions provided?
Given the opportunity, which of the
Continue receiving the Energy Break/Eat to Learn food box
two options would you prefer?
Receive the cash value to further supplement a school
nutrition program
AFS STUDENT NUTRITION PROGRAM
All elementary and secondary schools are eligible to participate in the Student
Nutrition Program. Would you like to participate in the 2008/2009 program?
Breakfast
Yes
No
Lunch
Number of operating days
Estimated number of students per day to access the program
Number of operating days
Estimated number of students per day to access the program
Planned Start Date
Planned Start Date
Order of Preference
Order of Preference
AM Snack/Nutrition Break
PM Snack/Nutrition Break
Number of operating days
Estimated number of students per day to access the program
Number of operating days
Estimated number of students per day to access the program
Planned Start Date
Planned Start Date
Order of Preference
Order of Preference
Will there be a cost to students participating in the program?
Yes
No
Yes
No
$
Will all students, parents, caregivers and staff be made aware that all students may
access the program regardless of their ability to pay?
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BREAKFAST FOR LEARNING
Algoma Family Services Student Nutrition Program will submit a group application to Breakfast for
Learning (BFL) for the school year 2008/2009.
Would you like Algoma Family Services (AFS)/Superior Children’s Centre
(SCC) to include your school in this group application? If yes, please complete
the attached Breakfast for Learning Nutrition Program Agreement (for
Group Applicants). (NOTE: A group application negates a school from
applying to BFL individually.)
Yes
Preferred language of correspondence:
French
English
Please select the type of program you would like
AFS/SCC to submit on your behalf.
Breakfast
No
Snack
Number of operating days
Estimated number of students per day to access the
program
Planned Start Date
Did you receive a BFL grant in 2007/2008?
Yes
No
From time to time, Algoma Family Services and Superior Children’s Centre has the opportunity to
secure extra funding through various avenues such as government grants, larger group contributions
from corporate sponsors, local charities, community organizations and municipalities.
Given the opportunity, would you like AFS/SCC to apply to other funders on your
behalf?
Yes
No
SECTION 3: LOCAL FUNDRAISING AND PARENTAL/CAREGIVER CONTRIBUTIONS
To operate successfully, school nutrition programs require support from a variety of contributors
including parents/caregivers, volunteers, local businesses and community organizations.
Check all that apply.
Who volunteers
for your
program?
(Please specify)
Principal/
Viceprincipal
Teachers/
Staff
Students
Parents/
Caregivers
Community
Members
Others
Financial
Contributions
Others
Estimate the total number of volunteers needed for the year 2008/2009.
How will parents/
Volunteering
caregivers be
involved in your
program?
(Please specify)
Fundraising
Menu
Planning
Shopping for
Supplies
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NOTE: All parents/caregivers are to be made aware of the cost of delivering the program and given the
opportunity to contribute financially to the program.
Please list fundraising initiatives and other financial supports anticipated for the school year 2008/2009;
e.g., student/parental contributions, grants, food or cash donations, etc.
FUNDRAISING INITIATIVES
ESTIMATED REVENUE
$
$
$
$
$
$
$
TOTAL
SECTION 4: NUTRITIOUS FOODS IN A SAFE ENVIRONMENT
Student Nutrition Programs are committed to improving the nutritional quality of foods provided. Please
refer to the “SNP Nutrition Guidelines” for details.
A breakfast or lunch should contain at least one serving form a minimum of three out of four food
groups of “Canada’s Food Guide” with at least one serving from the Vegetables and Fruit food group
and at least one serving from the Milk Products food group.
A snack should contain at least one serving from a minimum of two food groups of “Canada’s Food
Guide” with at least one serving from the Vegetables and Fruit food group.
Please complete the attached “Menu Planner”on page 6.
Check all that apply.
Who will
participate
Principal/
Teachers/ Program
in planning ViceStaff
Coordinator
the menu?
Principal
Will program volunteers be trained in food safety?
(Please specify)
Dietitian
Parents/
Caregivers
Others
Yes
No
Yes
No
Yes
No
Yes
No
If no, please explain.
Are you interested in training opportunities; e.g. how to read food
labels, plan a menu and food safety?
Did you, or do you plan to consult with a Public Health
Inspector/Environmental Health Officer in planning your program?
Do you require any equipment for your new or existing program; e.g.
industrial toaster, fridge, microwave, etc.?
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Please list any equipment or supplies your school requires to improve the quality and efficiency of your
school nutrition program.
EQUIPMENT/SUPPLIES REQUIRED
TOTAL
ESTIMATED COST
$
$
$
$
$
$
$
SECTION 5: LOCAL SCHOOL COMMITTEE
Who will coordinate the program?
Will there be a committee to assist in organizing the program?
Yes
No
If yes, how many members will be on the committee?
Please check
Principal/
anticipated
Vicecommittee
membership. principal
(Please specify)
Teachers/
Staff
Students
Parents/
Caregivers
Community
Members
Others
SECTION 6: FINANCIAL AND REPORTING REQUIREMENTS
Monthly, schools will be expected to provide statistical data to Algoma Family Services/Superior
Children’s Centre. Statistical data will include:






School enrolment numbers
Number of children and youth served
Number of meals/snacks served
Additional sources of income; e.g., parent/caregiver donations, corporate sponsors, charities, etc.
In-kind contributions; e.g., number of volunteers, volunteer hours, food donations, etc.
Food receipts
Page 5 of 7
SECTION 7: OPERATING BUDGET WORKSHEET
If applying for multiple programs, please complete an “Operating Budget Worksheet” for each program.
Energy Break/Eat to Learn Program applicants do not need to complete this form.
1. FOOD
a) Cost per meal per student
$
b) Number of students
participating daily
c) Number of operating days
Total Food Costs = (a x b x c)
2. STAFFING
Salary/wages, honorariums,
transportation, training
To determine the cost per meal
 Prepare a basic weekly menu plan
 Refer to the attached “Food Costing List” to
determine the cost per serving for each food item
 Add up the costs for all food items




5 days per week = 190 school days
4 days per week = 152 school days
3 days per week = 114 school days
2 days per week = 76 school days
$
$
Staffing decisions should always be made in consultation with
the Program Committee.
If you are paying salary/wages, ensure that the appropriate
payroll deductions are withheld and remitted. Honorariums paid
to staff or volunteers may be subject to payroll deductions and
payments of more than $500 must be reported on a T4.
For more information, please visit the Canada Revenue Agency
website at www.cra-arc.gc.ca.
3. EQUIPMENT
Large and small appliances
4. SUPPLIES
Dishes, cutlery, cooking and
serving utensils, storage
containers, cleaning supplies, etc.
TOTAL EXPENSES
$
$
$
Reminder: Grants cover only a portion of
program costs
TOTAL GRANT REQUESTED
$
Any funds that are granted through this Student Nutrition Initiative must be used for the sole purpose of
purchasing nutritious food items only.
Page 6 of 7
School Name:
Select the type of program your school will offer:
MENU PLANNER
TEMPLATE 2008/2009
Healthy Meals &
Snacks
When completing your menu, please consider food allergies.
Breakfast
Sample
Snack Sample
Lunch Sample
(2-3 food groups)
(3 or 4 food
groups)
(3 or 4 food
groups)
Vegetables and
Fruit
½ lrg. banana
or 1 small 155g
Grain Products
oatmeal 28 gr.
Milk and
Alternatives
1 cup milk
250 ml
Apple 1 g
Monday
Tuesday
Wednesday
Thursday
Friday
1 small whole
wheat roll
1 cup yogurt
175 g
1 cup milk
250 ml
Turkey 2 slices
50g
Other Foods
Mayonnaise or
butter/margarine
$0.99
Menu Plan meets SNP Nutrition Guidelines
Comments:
1 leaf lettuce
1 carrot 72g
Meat and
Alternatives
Cost per
Meal/Snack
AM Snack/Nutrition Break
PM Snack/Nutrition Break
If applying for multiple programs, please complete a
menu planner for each program.
Student Nutrition Program
Food Group
Breakfast
Lunch
$0.79
$1.85
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