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RocketSCAN for Free & Reduced Meal Applications

2009 - 2010 ONLY!

To get started on application modifications, please fill out the form below and click submit. Use the comment section to add any ideas and suggestions on how we can create a better application this year. Your input is greatly appreciated! Each field in red is required. Filling out this questionnaire does not constitute an order; it WILL ENABLE Image One to provide you with a sample app and a proposal for your blank applications. The addition of features may cause additional costs to your order.

To fax a request, write out the desired changes and fax to (240) 218-8939.

District Information

School District
Contact Name
Phone Number
E-mail
State
Address to where the forms will be shipped after printing

Application Size
Please let us know the preferred dimensions you would like your form to be. We will do our best to accommodate the requested size content and state regulations permitting. All dimensions are in inches.

Application Dimensions

Application Amounts and Translations
Please provide us with exact amounts of each application type you will need for the 2009 - 2010 school year. There is a minimum order of 1,000 blank applications.

Blank English Applications with the instructions attached
(most common).

Blank English Applications with a household letter attached for district's that preprint student information on application.

Blank Spanish Applications with the instructions attached
(most common).

Blank Spanish Applications with a household letter attachedfor district's that preprint student information on application

Blank English Applications with a second language attached.

District will be providing Spanish translation?

Blank Portuguese Apps

District will be providing Portuguese translation?

Blank Creole Apps

District will be providing Creole translation?

Other languages

Number of other languages Apps

Would you like application on the front with the instructions on the back (most common) or English front with other language on back?

Image One offers the ability to set the forms up to be shipped faster. Please select any additional preparations you would like. These options may incur additional costs.
Please select the options you would like.	Would you like the application folded to fit a #10 envelope?
	Would you like the application inserted into a #10 envelope?
	Would you like the application mailed?

School Start Date?

POS Rollover Date?

POS Name?

Other POS name (if not listed above)?

Need Applications By? (date)

Training
Image One offers a training options that is designed to work around you schedule.

Image One offers a 3 hour RocketSCAN Refresher Training at $169 per district, per day. Are you interested?

Click HERE for additional information on this service.

Application Riders

What riders, if any, should be listed on your application (i.e. KidCare, SCHIP, etc)? Make your selections below:

None

FREE OR LOW-COST HEALTH INSURANCE: If your children get free or reduced price school meals, they may also be able to get free or low-cost health insurance from Medicaid or the State Children's Health Insurance Program (SCHIP). We will tell Medicaid and SCHIP that your children are eligible for free or reduced price meals and program officials may contact you to enroll your children (they are not automatically enrolled) if you sign the box below. If you do not sign, then your children may not have the opportunity to participate in this program. [ SIGNATURE BOX ]

Check here if you want to give school officials permission to use the information provided on this application to determine your child(ren)'s eligibility for other state or federally funded school related benefits. [ Check Box ]

Other - Use the text box below to input rider information.

Race & Ethnicity
Do you require a Race/Ethnicity section?

Yes, we will need a Race/Ethnicity section.

No, we do not need a Race/Ethnicity section. We obtain this information from other programs or applications.

School Meal Pricing
What are your school meal prices for 2009 - 2010?

Breakfast for Elementary

Breakfast for Secondary

Reduced Price Breakfast

Lunch for Elementary

Lunch for Secondary

Reduce Price Lunch

Other pricing

Important Contact information
The following information will appear on the instruction portion of the application.

Food Services Department
Phone Number

Fair Hearing Officer Name

Fair Hearing Officer Address

Fair Hearing Officer
Phone Number

Homeless Liaison Phone Number

Migrant Coordinator Phone Number

Temporary Income
Do you require that your meal applications request temporary income?

No, we DO NOT need to determine Temporary Income

Yes, we would like to request for Temporary Income.

Submit Instructions
Please list any special instructions on how the application should be submitted when complete (i.e. Please mail to..., Return to School, etc.)

Types of Benefits
Please list out each program accepted by your county (i.e. Food Stamp, TANF, Kin-Gap, CalWORKS, KTAP, etc).

Signing Official
Please list the name and title of the signing official. We can place a graphic of their signature on the instruction sheet.

Signing Official

Title

Would you like this signature to be on the instruction portion of the form?

If you answered yes to having the signature placed on the instructions, how are you going to supply it to us?

Comments & Suggestions
Use the box below to make any comments or suggestions.

I have read through and understand that this form is not a sales agreement and does not constitute and order. Prices may vary based on features ordered.

I agree I don't agree

Upon submission of this form you will receive confirmation.