Thank you for your interest in partnering with Second Harvest Foodbank of Southern Wisconsin to end hunger in your community. If you have questions about the application process, please contact Ann De Tienne at 608-216-7207, or annd@shfbmadison.org. Process for embership: (typically takes 2-3 weeks from the time your application is received) 1. Complete Quick Evaluation tool, found on the Second Harvest Foodbank (SHFB) website, to see if your agency may qualify for membership. 2. Review the membership agreement located on the website to ensure your agency can agree to the terms of membership, if your application is approved. 3. Submit completed application and any supporting documentation to SHFB. 4. Second Harvest will review your application packet, contacting you with any questions we may have, and we will let you know whether or not your application can proceed as is to the next step. 5. oving forward, a Second Harvest staff member will contact you to set up a time for your initial site visit, and to arrange the completion of any safe food handling training. 6. If your application is approved for membership, you will be asked to submit a signed membership agreement. After receiving the agreement, we will enter your agency and program information into our database. You will be assigned a program number and will be given detailed instructions on how to order food from the Foodbank. 7. The primary contact for the program will need to attend a formal embership Orientation at the Foodbank within 2 months of membership approval. ore program staff/volunteers are also welcome to attend. Checklist of Items Needed for Completed Application: Completed Quick Evaluation Tool Completed embership Application form for each program that seeks food from SHFB Copy of documentation of IRS non-profit status (one of these) IRS Letter of Determination of 501(c)(3) status Proof of affiliation with recognized church For churches without proof of affiliation with a recognized church: 14 Point Letter with associated documentation attached List of current board of directors or church council, and copy of most recent annual meeting minutes (or of initial charter, if less than one year old) Brochure, advertisement, flyer, etc. showing your program s mission to assist low-income people. Completed site visit form (administered by SAR) Proof of registration with 2-1-1, if applicable Client check-in or data collection form Proof of Safe Food Handling training (this must be completed prior to final application approval) Proof of professional pest inspection (this must be provided within 30 days of application approval) 2802 Dairy Drive adison, WI 53718
embership Application General Information (The agency name may differ from the program name. For example, a food pantry located at a church will show the agency name as the name of the church, and the name of the pantry is the program name.) Agency Name: Street Address: City: Zip Code Agency Director: Director Title: (Executive Director, Pastor, etc.) Phone Number for Agency Director: Fax Number: Email: Program Information (Any subset of the agency that distributes food separately is a different program, i.e. shelter, day care, pantry, and should complete a separate application and each program will need a site visit before receiving food from Second Harvest.) Program Name (if different from agency name): Street Address (if different from above): City: Zip Code: County: Contact Person: Contact Phone: Email: Program FAX: Phone Number at Program Location: 2802 Dairy Drive adison, WI 53718 2 P a g e
Billing/ailing Information Billing Contact Person: Bill to Agency Name: Bill to Address: City: Zip Code: Billing Contact Phone Number: Fax Number: Agency Eligibility Information (Please Check ONE) Our agency is a 501(c)(3) non-profit organization. It is not a private foundation or a municipality. Please attach IRS Letter of Determination of 501(c)(3) status. Our agency is part of a larger organization (Ex: Salvation Army, YCA, LSS, Catholic Charities, etc.). Please attach IRS Letter of Determination of 501(c)(3) status of the larger group AND documentation from the larger group connecting you to this organization. Our agency is a church that is part of a larger denomination (Ex: Catholic, Baptist, Lutheran, etc.) Please attach documentation connecting you to the larger denomination. Our agency is a church and is not part of a larger denomination and we do not have our own 501(c)(3) Please attach the 14-point Qualifying letter. (See page 9.) The program for which we are applying for membership with Second Harvest is listed on 2-1-1. Yes (attach proof of registration) No (please explain): Will register with 2-1-1 if our application for membership is accepted We realize that registering with 2-1-1 is not appropriate for all programs seeking membership with Second Harvest. For any program that is or should be open to the public, registration with 2-1-1 is required. 2802 Dairy Drive adison, WI 53718 3 P a g e
Program Information Your agency should have an established emergency food program or should be a reputable organization with a history of helping those in need. SHFB will serve only organizations providing onsite feeding and/or emergency food assistance. 1. Our agency is applying as the following (Please Check ONE): Food Pantry On-site eal Program (We are not accepting applications for individual or group homes.) Type of on-site meal program (check one): Soup Kitchen Homeless Shelter Domestic Abuse Shelter After School/Youth eal Program ental Health Program Senior eal Program Other: Food Pantry AND On-Site eal Program [you should be using multiple applications] 2. How long has this program been operating? 3. What geographic area do you serve? 4. Is service limited to residents of that area? 5. What outreach is currently done to inform those in need of your program that your program exists? 6. Please provide a description of the single program for which this application seeks food from Second Harvest, and include how food for the needy is incorporated into this program. (Attach brochure/annual report, if possible.) 7. Does your agency require clients to pay and/or do you require or strongly encourage a donation for the food that they receive? Yes No (Explain, if yes): 2802 Dairy Drive adison, WI 53718 4 P a g e
8. Does your agency charge clients for other services that your program provides? Yes No (Explain, if yes) 9. Does your agency, or any of its programs, require work or participation in any ceremonies or services as part of receiving food? Yes No (Explain, if yes) 10. What are the eligibility requirements for clients to receive food? 11. How do you determine client eligibility? 12. What percentage of your clients are low-income? (Second Harvest defines low income as no more than 200% of the Federal Poverty Guidelines.) The 2017 Poverty Guidelines for the 50 States and the District of Columbia Below are the 2016 poverty guidelines that were published in the Federal Register, effective immediately. Household Size 200% onthly 200% Annual 1 $2,010 $24,120 2 $2,707 $32,480 3 $3,403 $40,840 4 $4,100 $49,200 5 $4,797 $57,560 6 $5,493 $65,920 7 $6,190 $74,280 8 $6,887 $82,640 For each additional person, add $697 $8,360 2802 Dairy Drive adison, WI 53718 5 P a g e
13. Do you store/distribute/prepare/serve food at any location(s) other than the Agency Address? Yes No Please list each additional address (If food is prepared at one location and served at another, or stored at one location and distributed at another, please specify): 14. What month(s) do you operate the food program? Year-Round January February arch April ay June July August September October November December 15. Have any of your primary staff or volunteers received food safety training? Yes No 16. Are any of your primary staff or volunteers certified in safe food handling? Yes No If yes, what certification do they have? When does the certification expire? 17. What are your food program s days and hours of operation? onday Tuesday Wednesday Thursday Friday Saturday Sunday 18. How many families/households do you serve per month? 19. How many adults do you serve per month? 20. How many children do you serve per month? (Actual or estimate?) 21. How many elderly (60 and over) per month? (Actual or estimate?) (Attach copy of client check-in or data collection form) 2802 Dairy Drive adison, WI 53718 6 P a g e
Resources 22. What is the main source of monetary funding for your agency? 23. From what sources will you continue to receive funding for your agency? 24. Where do you currently get your food? 25. Are you familiar with the FoodShare Program (also known as SNAP, formerly food stamps)? Yes No If yes, do you provide your clients with information about FoodShare? Yes No 26. What other resources or information does your program offer your clients? 27. What plans, if any, do you have to expand your program or what you offer to clients? Food Storage 28. Does your agency/program currently have a professional pest control contract to cover wherever food is stored, prepared, or served? Yes No Comments: 29. What type of food storage do you presently have? (Check all that apply.) Dry storage/shelving Refrigerator/Cooler Freezer Other: 30. Is program food secured to prevent theft or tampering? (i.e. a locked room, locks on cabinets or cooling units, etc.) Yes No Comments: 2802 Dairy Drive adison, WI 53718 7 P a g e
Authorized Shoppers 31. As agency director or pastor, I give approval for the following individuals to order or pick up food from Second Harvest on behalf of our agency (limit 5). An email address is necessary to enter them in our system. All shoppers will also be included in our e-blasts, which often contain information pertinent to shopping. E-blasts typically occur 2x/month. 1. Name: email address: 2. Name: email address: 3. Name: email address: 4. Name: email address: 5. Name: email address: Food Pantry Programs Only 32. Does your pantry limit the frequency or number of times a client can utilize the pantry? Yes, please explain No 33. How many days of food are given to clients? (Day=Three eals) 34. Our pantry: Distributes pre-bagged food Lets clients select their items Accounts for family size Accounts for special needs (infants, special diets) Other For eal Programs Only 35. What meals are regularly served by your program? (Check all that apply.) Breakfast Lunch Dinner Snack 36. Of the different types of meals you serve, how many do you serve each week? Breakfast eals: Lunch eals: Dinner eals: Snacks: 2802 Dairy Drive adison, WI 53718 8 P a g e
Religious Organizations Only 14-Point Criteria Letter (must meet at least eight criteria points, and provide supporting documentation where applicable) Please mark each item that your church meets: 1) A Distinct Legal Existence 2) A Recognized Creed and Form of Worship 3) A Definite and Distinct Ecclesiastical Government 4) A formal Code of Doctrine and Discipline 5) A Distinct Religious History 6) A embership Not Associated with any (other) Church or Denomination 7) A Complete Organization of Ordained inisters inistering to their Congregation 8) Ordained inisters Elected After Completing Prescribed Courses of Study 9) A Literature of Its Own 10) Established Places of Worship 11) Regular Congregations 12) Regular Religious Services 13) Sunday Schools for Religious Instruction of the Young 14) Schools for Preparation of its inisters Church Name: Church Address: City: Zip Code: Signature of Pastor, Priest, Rabbi or other Legally Authorized Agent Date Signed 2802 Dairy Drive adison, WI 53718 9 P a g e
I have read and understood the membership agreement, as found on the Second Harvest website, which I will be required to sign if this application is approved for membership. (Check one.) Yes No If approved for membership, my agency will be interested in receiving delivery service, which we understand requires a 500-lb order minimum, and a $20 flat fee per delivery. (Check one.) Yes No I certify that the above application is complete and the information is true and correct to the best of my knowledge. I understand that false information on this application may be grounds for non-approval of application or termination of agency s membership with Second Harvest Foodbank of Southern Wisconsin. Agency Director (Executive Director, Pastor, etc.) Date Program anager (if different) Date Be sure to keep a copy of the completed application packet for your files. Application packets should be sent to Ann De Tienne in one of the following ways: Via email: annd@shfbmadison.org Via fax: 608-223-9840 Via mail: Second Harvest Foodbank of So. WI 2802 Dairy Drive adison, WI 53718 Thank you for taking the time to complete this application. 2802 Dairy Drive adison, WI 53718 10 P a g e