Food Bank of Central Louisiana
BackPack Program Site Application

School or Agency

Name of Principal or Director

School/Agency Address

Address 2

City/Town

State

ZIP

Parish

Name

Email Address

Phone Number

How many of your students would you estimate are chronically hungry?

What percentage of your students participate in the Free/Reduced Price Lunch Program?

Hours of Operation

Ages of Students Served

	Yes	No
Is there a location available to store boxes from delivery until distribution?	Is there a location available to store boxes from delivery until distribution? Yes	Is there a location available to store boxes from delivery until distribution? No
Can food be stored at least six inches off the floor?	Can food be stored at least six inches off the floor? Yes	Can food be stored at least six inches off the floor? No
Is the area secure?	Is the area secure? Yes	Is the area secure? No
Is there a loading dock, or other location to receive deliveries?	Is there a loading dock, or other location to receive deliveries? Yes	Is there a loading dock, or other location to receive deliveries? No

Name

Title/Position

Food Bank of Central LouisianaBackPack Program Site Application