Medical Statement to Request Special Meals and/or Accommodations

MOTHER LODE UNION SCHOOL DISTRICT
FOOD SERVICE DEPARTMENT
3783 FORNI ROAD
PLACERVILLE, CA 95667
PH (530) 622-4814 or FAX (530) 626-7284

Welcome to the Mother Lode Union School District Food Service Program. Attached you will find information and an application for the Free/Reduced Meal Program. If you feel you qualify, complete this application listing all children and adults living in the household and proof of income and return it to your child’s cafeteria for determination. You will receive notification within 10 working days as to the status of your application:

If you are approved for Reduced Meals or need to pay Full Price, the costs are:

Reduced Breakfast	$. 30	Full Price Breakfast	$1.75	Adult Price Breakfast	$2.25
Reduced Lunch	$. 40	Full Price Lunch	$3.25	Adult Price Lunch	$3.75

White Milk	$. 50	Chocolate Milk	$. 50

You can prepay for more than one meal at a time if you prefer. The Food Service Department encourages prepayment for the ease of the child.

• You can pay daily by check or cash
• You can pay On Line.
• You can pay in advance by check or cash.
• You can pay by mail. All payments by mail must be sent to:

Indian Creek Elementary School
Food Service Department
Attention: Kathy Correia

6701 Green Valley Road
Placerville, CA 95667

Please allow 1-2 days for credit to show on the computer.

If you send checks for more than one child, please list your children’s first and last name and the amount of money you want applied to each child’s account.

REMEMBER: Free and Reduced status means: (1) Free is entitled to a free breakfast and a free lunch. (2) Reduced will receive a breakfast for $.30 and a lunch for $.40. Lunches for field trips are available and must be ordered in advance with the Field Trip Permission Slip.

The Food Service computer system can accommodate three (3) lunch charges. If your child has two (2) charges on his/her account, he/she will not be allowed to charge again. When this occurs, as a courtesy we will stamp your child’s hand as a reminder to you that money is owed on their account. They will be given a snack of our choice, so no child will go hungry. Reduced students are given the school lunch of the day. Be aware that often children get confused, scared, or embarrassed to ask about a meal. They will sit at the table with nothing to eat without our knowledge. It can be a traumatic experience for some children, so please keep as close account as possible of your child’s Food Service account. A “memo” showing monies in the account or any existing charges due, can be obtained by asking the Food Service Cashier. If there is a discrepancy with your child’s account or if you have any concerns, please call Kathy Correia at 622-4814 between the hours of 6:00 am and 2:00 pm.