HomeMy WebLinkAbout065567 - General - Contract - Fort Worth ISDCSC No. 65567
FORT WORTH INDEPENDENT SCHOOL DISTRICT CHILD NUTRITION SERVICES OFFICIAL RECORD
AFTER SCHOOL SUPER SNACK PROGRAM AGREEMENT CITY SECRETARY
2026 - 2027
(Please fill out one agreement per campus program.) FT. WORTH, TX
➢ After the completed "After School Super Snack Program Agreement" is received at the CNS Central Office,
the coordinator will be notified of the start date for dinner.
➢ The CNS manager cannot start a program unless authorization has been given from CNS Central Office.
➢ Please provide a minimum of two weeks advance notice to program start date. Please notify CNS Dietitians with
any change in program start and/or end dates.
School Name EM Daggett Elementary School Site#
Name of Campus Organization: City of Fort Worth, Fire Station Community Center
Type of Program: (Tutorial, Enrichment, etc.) After School Program
Program/site Coordinator Name: Monica Lara
Completed Civil Rights Training: Yes ❑ No ❑
E-mail: Monica.Larakfortworthtexas.gov
What time does program start? ❑ 3:15pm ES
04:00pm Leadership Academy
Phone #: 817-965-6863
❑ 3:45pm HS ❑ 4:30pm MS
( ) Reimbursable Super Snack— Includes: Meat/Meat Alternate/Fruit/Vegetable/Milk
Program Start Date: August 10, 2026 Program End Date: May 26, 2027
What days are meals needed? Check all that apply:
(X ) Monday (X ) Tuesday ( X ) Wednesday ( X ) Thursday (X ) Friday
Number of Meals Needed Daily: 120
Terms & Conditions
I understand that the after school supers rack program agreement must be approved before program begins. Please
provide 2 weeks advance notice of program start date. Please notify CNS Dietitians of any change in program start
and/or end dates.
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Dana Burghdoff (Jul 24, 2P26 14:59:59 CDT)
Site Supervisor/Contact Signature + Date Signature of Principal + Date
My signature confirms that I have read all of the terms and conditions and will comply with all of the
guidelines.
Email completed forms to CNS Dietitians
Phone: 817-814-3500 Email: dietitians@fwisd.org
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the
basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program
information maybe made available in languages other than English. Persons with disabilities who require alternative means of cam municationto obtain program information
(e.g.,Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA's TARGETCenter at
(202) 720-2600 (voice and TTy) or contact USDA through the Federal Relay Service at (800) 877-8339. Toole a program discrimination complaint, a Complainant should complete
Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-
Complaint-
Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant's
name,address, telephone number, and a written description of the alleged discriminatory action insufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about
the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted 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(ausda.gov. This institution is an equal opportunity provider.
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Child Nutrition
Revised 7/2026
FOR CITY OF FORT WORTH INTERNAL PROC SSES:
Approval Recommended:
By:
Name
Title:
By:
Name
Title:
Dave Lewis
Director
Park & Recreation Department
Monique Hill
Assistant Director, Recreation
Park & Recreation Department
Contract Compliance Manager:
By signing I acknowledge that I am the person
responsible for the monitoring and administration
of this contract, including ensuring all
performance and reporting requirements.
By:
Name:
Title:
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Sheri Endsley
District Superintendent
Park & Recreation Department
City Secretary:
Approved as to Form and Legality:
By: ll
Name: Jannette S. Goodall
By: Title: City Secretary
Name: Hye Won Kim
Title: Assistant City Attorney
Contract Authorization:
M&C: N/A
Form 1295: N/A
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OFFICIAL RECORD
CITY SECRETARY
FT. WORTH, TX
FORT WORTH.
City Secretary's Office
Contract Routing & Transmittal Slip
Contractor's Name: Fort Worth Independent School District
Subject of the Agreement:
Elementary School
After School Super Snack Program Agreement with FWISD at EM Daggett
M&C Approved by the Council? * Yes ❑ No M
If so, the M&C must be attached to the contract.
Is this an Amendment to an Existing contract? Yes ❑ No 0
If so, provide the original contract number and the amendment number.
Is the Contract "Permanent"? *Yes ❑ No 0
If unsure, see backpage for permanent contract listing.
Is this entire contract Confidential? *Yes ❑ No 0 If only specific information is
Confidential, please list what information is Confidential and the page it is located.
Effective Date:
If different from the approval date.
Expiration Date:
If applicable.
Is a 1295 Form required? * Yes ❑ No ED
*If so, please ensure it is attached to the approving M&C or attached to the contract.
Project Number: If applicable.
*Did you include a Text field on the contract to add the City Secretary Contract (CSC)
number? Yes 0 No ❑
Contracts need to be routed for CSO processing in the followingorder:
rder:
1. Katherine Cenicola (Approver)
2. Jannette S. Goodall (Signer)
3. Allison Tidwell (Form Filler)
*Indicates the information is required and if the information is not provided, the contract will be
returned to the department.