Please Enter Your Information Below Only List Children That Live In The Household

Please Enter Your Information Below Only

List Children That Live In The Household

Directions: Complete by May 1, 2026. Call 334-614-6538 if needed.

Please Select Which Area You Currently Live In Below 👇 ( if your area is not listed we don't deliver there currently) *

Date *

Parent/Guardian Name *

Phone *

Email *

Address *

Street Address

City

State

Country

Postal Code

Meal Option (Delivery of Pick up) *

Child Information
Enter each child’s name, age, school, and allergies below.

Child Name 1 *

Child Age 1 *

Child School 1 *

Child Allergies 1

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Child Name 2

Child Age 2

Child School 2

Child Allergies 2

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Child Name 3

Child Age 3

Child School 3

Child Allergies 3

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Child Name 4

Child Age 4

Child School 4

Child Allergies 4

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Child Name 5

Child Age 5

Child School 5

Child Allergies 5

Authorized Pick-Up Contacts
Only these individuals may receive meals with ID.

Authorized Contact Name *

Authorized Contact Phone Number *

Signature *

Clear

Signature Date *

Home Delivery Certification *

I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that meals provided through the Summer Food Service Program are intended only for eligible children residing within my household and delivered to the address listed on this form. I understand that providing false or misleading information may result in disqualification from participation in meal delivery services and may be referred for further review. By signing this form, I acknowledge that Miles of Purpose may contact me to confirm household information, delivery address information, meal delivery information, and participation details.