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White Settlement ISD Child Nutrition Programs

Account Restriction Form-Elementary

If you choose to restrict your child on what they may purchase, a message will appear on the students lunch account.

Please indicate below and return this form to your child’s school cafeteria or email to adam.whitten@wsisd.net or ycarrasco@wsisd.net.

Please check the following choices:

_________ Meal Only (Breakfast or Lunch meal only, No: extras, snacks, water, etc….)

_________No Breakfast

_________No snacks (ex. Chips, cookie, HS-Gatorade,HS & MS 12oz drinks)

_________Snacks on Friday only (or specify day or days)

_________No extras (ex. Entrees, extra fruit or vegetable, bottle water)

_________Cash only for snacks (must have cash in hand)

_________Other

School: ____________________________________

Name of student _____________________________ Account number______________

Parent/Guardian _____________________________

Download the Account Restrictions Form Here, and then return it to your Child's School Cafeteria

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, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

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 responsible Agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or 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 discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at 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.

USDA is an equal opportunity provider, employer, and lender.

WSISD Child Nutrition Office | 8224 White Settlement Road | White Settlement, TX 76108 | (817) 367-1310 | Fax (817) 367-1223

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