WAIVER FROM PARTICIPATING IN THE SCHOOL BREAKFAST PROGRAM (SBP) APPLICATION

for the Coming School Year (SY)

Due to Child Nutrition & Wellness the third Friday in April

SCHOOL DOES NOT OFFER BREAKFAST

See back of form for instructions.

A waiver does not relieve the responsibility of the site to provide morning nutrition to students

whodemonstrate a need for nutrition in the morning.

USD Number: USD Name:

1.

School Building(s) / A.
Total Number of Students Eligible for Reduced Price and Free MealsMarch (Current SY) / B.
Total Enrollment
March
(Current SY) / C.
% Eligible for Reduced Price and Free Meals
Must be <35%
(A ÷ B x 100)

2. There iscurrently no evidence of need for the School Breakfast Program (SBP) in this/these school(s). The need for the SBP must be evaluated annually. For each school building, explain how information was obtainedwithin the last year (since January of the prior SY) that led to the determination that the SBP is not needed at this/these school(s).

Explain the documentation that supports the present determination that the SBP is not needed at this/these school(s). Attach additional page(s) as necessary.

3.The school mustestablish policy and procedures that address the needs of students requiring morning nutrition to be effective and active learners to be eligible for a waiver to not participate in the School Breakfast Program.

Food is available in the following ways: (check all that apply)

No food is served in the building before or during the morning hours.

SBP served in the cafeteria where lunch is served for this building; students have the same

access as at lunch (i.e. transportation is required if provided at lunch).

Ala carte foods are available from school food service; cash is required.

Ala carte foods are available from school food service; student meal accounts may be used.

Foods are sold in the morning by vending machines, school stores or organizations. Cash is required.

Other: Explain

4. Attach the policy and procedure as distributed to faculty, parents, and students. Policy and procedure

should address at a minimum the (1) morning nutrition provided (2) in this building, (3) to any student

(4) regardless of the ability to pay.

Contact Person / Phone Number
______
Signature of Superintendent / Date

INSTRUCTIONS FOR SBP WAIVER APPLICATION

SCHOOL DOES NOT OFFER BREAKFAST

Complete this form for any school building(s) that had a School Breakfast Program (SBP) Waiver in
the current School Year (SY) and request(s) a SBP waiver for the coming SY. The criteria for the SBP Waiver are in bold print.

Indicate the USD number and name.

  1. Fewer than 35% of students in attendance are eligible for Reduced Price and Free meals.
  1. List the school building(s) for which a waiver is requested. School names should be listed as found on Site Applications of the Program Agreement with Child Nutrition & Wellness, KSDE. School building(s) with similar characteristics may be included on the same application form.

For each school building requesting a waiver:

B.Record the total number of students eligible for reduced price and free meals in March (Current SY).

C.Record the total enrollment in March (Current SY) (include Kindergarten if they receive breakfast).

D.Calculate the percentage (%) of students in attendance in March (Current SY) eligible for reduced price and free meals (divide the number in column B by the number in column C and multiply by 100).

Buildings with 35% or more of enrolled students eligible for reduced price and free meals cannot be considered for a SBP waiver. Contact Child Nutrition & Wellness for assistance in providing economical, efficient breakfast programs.

2.There is currently no evidence of need for the School Breakfast Program.

For each school explain information evaluated within the last year that led to the determination that the SBP is not needed at this/these school(s). Documentation must reflect current enrollment. Surveys and pilot projects must have been conducted since January of the prior SY. Documentation may include one of more of the following:

  • site council reports
  • district demographic analysis
  • survey information
  • reports of pilot breakfast program

Attach additional page(s) as necessary.

3.To be eligible to apply for a waiver from participating in the SBP, the school must establish policy and procedures that address the needs of students requiring morning nutrition to be effective and active learners.

Indicate what forms of nutrition are available in the morning to students in this building and if only cash options are available indicate how students who need nutrition can be provided it without overt identification of eligibility or non-eligibility for reduced price or free meals.

4. The policy and procedures as distributed to faculty, parents and students must be enclosed with the

waiver request.

Attach additional page(s) as necessary.

Enter the name and telephone number of the person who should be contacted if there are any questions concerning the application. All SBP waiver applications must be signed by the Superintendent and dated.

Return to Child Nutrition & Wellness, Kansas State Department of Education, Landon State Office Building, 900 SW Jackson Street, Suite #251, Topeka, KS 66612 on or before the third Friday in April.

If you have questions, contact Child Nutrition & Wellness 785-296-2276.