Education Meal Plan

EDUCATION MEAL PLAN

This Education Meal Plan Enrollment and Agreement ("Agreement") establishes the student's participation in the school meal service and sets forth the obligations of the signatory for payment, dietary accommodations, account management, and program rules. School Name:

Student Information

Date of Birth:    Student ID:    Grade/Program:

Primary Phone:    Email:

Parent / Guardian (if student is a minor)

Relationship:    Phone:    Email:

Meal Plan Selection & Term

Choose the meal plan to be provided under this Agreement (select one or more as applicable):

Full board (all meals provided on service days)
Partial board (specified meals per week)
Pay-as-you-go / Declining balance account
Other (describe):

Plan Start Date:    Anticipated End Date:

Billing, Fees, and Payment

The signatory accepts financial responsibility for meal charges incurred under this Agreement. Charges will be billed according to the selected plan and school billing cycles. Select payment method:

Billed to student account
Credit card on file
Prepayment / Deposit
Financial assistance / Scholarship applied

Refunds and adjustments will be issued only in accordance with school policy. The signatory acknowledges that unpaid balances may result in suspension of meal service and may be referred for collection.

Dietary Restrictions, Allergies, and Medical Accommodations

Does the student require special dietary accommodation for medical or religious reasons? Yes No

Allergies (check all that apply):
Milk/Dairy   Eggs   Peanuts   Tree Nuts
Shellfish   Wheat/Gluten   Soy   Other (specify below)

Physician/Medical Provider must provide written documentation for medically necessary meal modifications. Physician Name:    Phone:

Emergency Contact & Medical Information

Emergency Contact Phone:    Primary Care Provider:

Policies, Acknowledgements, and Legal Terms

By enrolling, the signatory agrees to the following substantive terms: the school will provide meals in accordance with the selected plan and documented accommodations; the signatory authorizes the school to share necessary dietary and medical information with food service and nursing staff for the purpose of safely providing meals; the signatory remains financially responsible for charges incurred under this Agreement.

Cancellation: The signatory must provide written notice to the school to cancel or modify the meal plan. Cancellation requests received less than five business days before the next billing cycle may not be effective until the following billing period. Refunds, if any, will be issued only in accordance with school policy.

Liability and Indemnity: The school shall exercise reasonable care in the preparation and service of meals. The signatory releases the school and its employees from liability for adverse reactions resulting from undisclosed allergies, failure to supply accurate medical information, or intentional noncompliance with accommodation instructions. The signatory shall indemnify the school for claims arising from inaccurate or incomplete information provided by the signatory.

Data Use and Recordkeeping: Meal program records, including dietary and billing information, shall be maintained in school records for administrative purposes. Records will be used only for meal provisioning, billing, accommodation verification, and internal reporting.

Certification: I certify under penalty of school disciplinary action and applicable law that the information provided on this form is true and complete to the best of my knowledge. I have read, understand, and agree to the terms of this Agreement and the meal program policies described above.

I attest that the information provided is accurate and that I accept financial responsibility as described.
I understand that medical documentation is required for dietary accommodations and that failure to provide documentation may result in denial of modifications.

Additional Notes

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