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  Image One Corporation
(800) 956.9000 x210
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Go Back RocketSCAN for Free & Reduced Meal Applications
2007 -2008 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.

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 preffered dimensions you would like your form to be. We will do our best to accomodate 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 2007 - 2008 school year. There is a minimum order of 1,000 blank applications.
Blank English Apps
Blank Spanish Apps
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 or English front with other language on back?
School Start Date?
POS Rollover Date?
POS Name?
Other POS name (if not listed above)?
Need Applications By?

Training
Image One offers 2 training options that are designed to work around your schedule.
Do you prefer to attend training at Image One's training center or at your school district?
How many people will be attending the training?

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 2006 - 2007?
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.


Upon submission of this form you will receive confirmation.

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