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CACFP Parent/Guardian Pick-Up Waiver Form
* Please note this must be submitted ONLINE and Through Paper BY ALL SITES administered by PCCPA* 

This request form is strictly for CACFP facilities that are under the sponsorship of PCCPA. Contact our office or  your sponsor rep for flexibility during disasters.
Complete the form below to request permission for non-congregate (Grab-and-Go) meals to be picked up by Parents/Guardians.

Once submitted , you will have CONDITIONAL permission to ALLOW FOR the pick up of meals AND STILL claim the meal for reimbursements for enrolled children,  or in cases of at-risk sites qualified children.  READ EACH CONDITION CAREFULLY BEFORE COMPLETING THE FORM.

An individual request must be made for each site.

Organization's Name: Professional Child Care Provider Association
Agreement Number: 05144

    Please Fill Out Completely 

    Waiver REQUEST: PARENT PICKUP METHOD
    If choosing Option 1: Valid forms of ID may include, but are not limited to, school identification card, participant’s passport, government-issued child identification card, or any document proving parent/guardian identity and relationship to the child or adult, such as an adoption decree; doctor, clinic, or hospital record; religious record; or daycare center record.

    If choosing Option 2: PCCPA recommends that collection of household information be done by the Program sponsor’s staff to minimize contact.

    If choosing Option 3: Please explain your proposed method of verification in the details below.

    Please Agree to Following Declaration 
    ​
Main Office - Houston: 9894 Bissonnet Suite 110 Houston, TX 77036
Austin: 2021 Guadalupe Street Suite 260, Austin, TX
Sugar Land: 1601 Industrial Blvd Suite 3079, Sugar Land, TX 77498
College Station/Bryan: 4040 Texas 6 Frontage Road Ste 101A College Station, TX
USDA Nondiscrimination Statement (English)
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits.  Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992.  Submit your completed form or letter to USDA by:
(1)    mail:        U.S. Department of Agriculture
                        Office of the Assistant Secretary for Civil Rights
                        1400 Independence Avenue, SW
                        Washington, D.C. 20250-9410;
(2)    fax:          (202) 690-7442; or
(3)   email:      program.intake@usda.gov.
This institution is an equal opportunity provider.
USDA Nondiscrimination Statement (Spanish)
De conformidad con la Ley Federal de Derechos Civiles y los reglamentos y políticas de derechos civiles del Departamento de Agricultura de los EE. UU. (USDA, por sus siglas en inglés), se prohíbe que el USDA, sus agencias, oficinas, empleados e instituciones que participan o administran programas del USDA discriminen sobre la base de raza, color, nacionalidad, sexo, discapacidad, edad, o en represalia o venganza por actividades previas de derechos civiles en algún programa o actividad realizados o financiados por el USDA.
Las personas con discapacidades que necesiten medios alternativos para la comunicación de la información del programa (por ejemplo, sistema Braille, letras grandes, cintas de audio, lenguaje de señas americano, etc.), deben ponerse en contacto con la agencia (estatal o local) en la que solicitaron los beneficios. Las personas sordas, con dificultades de audición o discapacidades del habla pueden comunicarse con el USDA por medio del Federal Relay Service [Servicio Federal de Retransmisión] al (800) 877-8339. Además, la información del programa se puede proporcionar en otros idiomas.
Para presentar una denuncia de discriminación, complete el Formulario de Denuncia de Discriminación del Programa del USDA, (AD-3027) que está disponible en línea en: https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complainty en cualquier oficina del USDA, o bien escriba una carta dirigida al USDA e incluya en la carta toda la información solicitada en el formulario. Para solicitar una copia del formulario de denuncia, llame al (866) 632-9992. Haga llegar su formulario lleno o carta al USDA por:
(1)  correo:        U.S. Department of Agriculture 
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2)  fax:             (202) 690-7442; o
(3)  correo electrónico: program.intake@usda.gov.
Esta institución es un proveedor que ofrece igualdad de oportunidades.
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