PROGRAM INFORMATION FOR PARENTS - 2021-2022 School Year FILLING IN THE BLANKS FIGHTS CHILDHOOD HUNGER BY PROVIDING CHILDREN IN NEED WITH MEALS ON ...
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FILLING IN THE BLANKS FIGHTS CHILDHOOD HUNGER BY
PROVIDING CHILDREN IN NEED WITH MEALS ON THE
WEEKENDS
PROGRAM INFORMATION FOR PARENTS
2021-2022 School Year
WWW.FILLINGINTHEBLANKS.ORG * 346 MAIN AVENUE,NORWALK CT 06851Free Weekend Food For Your Child Available through Filling in the Blanks!
Filling in the Blanks is a local non profit agency, located in Norwalk, CT that provides food on the
weekends to school aged children. We are teaming up with the staff and teachers at your child’s
school to offer a supply of nutritious meals and snacks to your child over the weekends and
extended breaks, FREE OF CHARGE. The goal of the Filling in the Blanks Program is to help
children thrive in school by offering additional nutrition on the weekends.
Sample bag of food can include:
2 Breakfast items (cereal or oatmeal packets)
4 snacks (Goldfish, fruit cup, apple sauce, granola bar)
2 individual sized cartons on shelf stable milk
1 can of vegetables or rice and beans
Combination of two items: Tuna, Soup, Mac & Cheese, Chef Boyardee or Canned Chicken
Bags are distributed by your child’s teacher on the last school day before the weekend or break.
Any child enrolled in a school we partner with is able to receive these weekly bags of food.
If you believe your child could benefit from this program, we encourage you to sign them up
using the OPT IN form, either at the bottom of this letter, or online at fillingintheblanks.org.
One form is needed for each child in your family. This information is kept confidential.
Once your child is signed up, they will receive a bag of food each week on Fridays, until they
leave the school or until you no longer wish to participate.
We encourage you to take advantage of this program for your child(ren).
Questions or concerns? Please contact your school’s front office or visit
www.fillingintheblanks.org for more information.
1OPT IN FORM 2021-2022
DATE
Dear Parent/Guardian,
Your child is eligible to participate in the Filling in the Blanks Weekend Food Program. The
program will run through the end of the school year. This program is designed for families who
are eligible for the free or reduce priced lunch programs, and those who have difficulty
accessing food on Saturday and Sunday.
Each Friday, your child will receive a bag of non-perishable, easy to prepare food for the
weekend. Bags will be distributed in a discreet manner by school staff. If you would like your
child to participate in the program, please sign below and return to the school social worker or
teacher immediately. Participation in this program will be on a first-come, first-served basis.
This is a FREE program.
Thank you!
-------------------------------------------------------------------------------------------------------------------------------
(please check box) I would like my child(ren) to participate in the Filling in the Blanks
Weekend Meal Program.
PLEASE PRINT CLEARLY
Parent Name______________________ Parent Signature____________________
Ethnicity _______________ Email Address ____________________
Cell phone ____________________ Home Zip Code ____________________
Student Name____________________M/F_____ Age_____ Grade________ School________
Additional siblings (each child will receive their own bag):
Student Name____________________M/F_____ Age_____ Grade________ School________
Student Name____________________M/F_____ Age_____ Grade________ School________
Student Name____________________M/F_____ Age_____ Grade________ School________
2DATE
Estimado/a padre/ madre o tutor/a
Su hijo/a cumple con los requisitos para participar en el programa de comidas para el fin de la
semana “Filling in the Blanks”. El programa durará hasta el fin del año escolar. Este programa
es designado para las familias que reciben el almuerzo gratis, especialmente aquellas que
tienen dificultad para obtener comida los sábados y los domingos.
Cada viernes, su hijo/a recibirá una bolsa de comida no perecedera para el fin de la semana. Las
Bolsas serán distribuidas por el personal de la escuela. Si usted quiere que su hijo/a participe
de este programa, por favor firme abajo y devuelva a profesor inmediatamente. La
participación en este programa es por orden de llegada. No hay costo para participar en este
programa.
¡Gracias!
------------------------------------------------------------------------------------------------------------------------------
(por favor ponga un check en la caja) Yo quisiera que mi/s hijos/as participaran en el
programa Filling in the Blanks Weekend Food en la escuela. Por favor, imprime claramente!
Nombre del Padre/Madre ________________________________________________
Firma del Padre/ Madre __________________________________________________
Dirección de correo electronic. ________________________________________________
Dirección. Ciudad Estado Código postal. ______________________________________
Teléfono celular ___________________________________
Nombre del
Estudiante________________.M/F_____Edad______Grado________Escuela_______________
Otros/as hermanos/as – (cada niño/a recibirá su propia bolsa):
Nombre del
Estudiante________________.M/F_____Edad______Grado________Escuela_______________
Nombre del
Estudiante________________.M/F_____Edad______Grado________Escuela_______________
Nombre del
Estudiante________________.M/F_____Edad______Grado________Escuela_______________
Para más información visite www.fillingintheblanks.org
3P
R
E
PRE SURVEY- PARENTS
We are gathering information to find the best way for us to help your child. Please provide us with
feedback by answering each question below. Thank you. Please return this survey to the school office
with your signed OPT-IN
1. What school does your child attend: ______________________________________________
2. What is your home zip code: ____________________________________________________
3. How do you identify yourself:
__ Black or African American __ Hispanic/Latino
__ Asian __ Multi-Racial
__ White or Caucasian __ Native American/Pacific Islander
__ Other
4. How do you identify your child:
__ Black or African American __ Hispanic/Latino
__ Asian __ Multi-Racial
__ White or Caucasian __ Native American/Pacific Islander
__ Other
5. How many people live in your home?
Adults (18 years and older) _______________________
Children (17 years or younger) ___________________
6. Do you ever run out of food at home?
____ yes ____ no ___sometimes ____on weekends
7. Do you ever skip a meal so that your child can eat?
____ yes ____ no ___sometimes ____on weekends
If yes/sometimes, how many times in the past month?
____ at least once ____ more than once ____more than 5 times
but less than 5 times
8. Do you have stress or worry that your food will run out before you have the money to buy more?
____ yes ____ no ___sometimes ____on weekends
9. Does your child ever complain about being hungry?
____ yes ____ no ___sometimes ____on weekends
10. Does your child ever have any of these symptoms due to hunger?
___ headache ___ disruptive behavior
___ stomachache ___ painful sensations
___ tiredness ___ my child does not have any of these
___ nausea symptoms
11. Do you think your family would benefit from Weekend food?
____ yes ____ no _____ don’t know
4PRE SURVEY- PARENTS
Estamos recogiendo información para encontrar la mejor manera de ayudar a sus hijos. Por
favor, provea la información y comentarios de valoración respondiendo a las siguientes
preguntas de abajo. Gracias. Por favor, devuelva esta encuesta a la oficina de la escuela antes
de—-
1. ¿A qué escuela asiste su hijo? _______________________________________
2. ¿Cuál es el área postal de su domicilio o residencia? ________________________
3. ¿Cómo se identifica usted?
_____ Afroamericano _____ Asiático
_____ Blanco o caucásico
_____ Hispano/Latino
_____ Nativo americano/ de las Islas del Pacífico ______ Multiracial
4. ¿Cómo identifica a su hijo?
_____ Afroamericano _____ Asiático
_____ Blanco o caucásico
_____ Hispano/Latino
_____ Nativo americano/ de las Islas del Pacífico ______ Multiracial
5. ¿ Cuántas personas viven en su casa? Adultos ( de 18 años o mayores) _________ Niños ( de
17 o menores). _________
6. ¿Alguna vez se quedan sin comida en casa?
_______sí _______no ________ a veces _______ en los fines de semana
7. ¿Alguna vez se salta una comida para que su hijo pueda comer?
_______sí _______no ________ a veces _______ en los fines de semana
Si respondió que sí, ¿cuántas veces el mes pasado?
________ Al menos una vez. ________Más de una pero menos de 5 _________Más de 5
8 ¿. Tiene estrés, tensión o preocupación de que se acabe la comida antes de tener el dinero para
poder comprar más?
_______sí _______no ________ a veces _______ en los fines de semana
9. ¿Se queja su hijo alguna vez de tener hambre?
_______sí _______no ________ a veces _______ en los fines de semana
10. ¿Tiene su hijo alguna vez alguno de estos síntomas debido al hambre? ______ Dolor de
cabeza ______ Dolor de estómago
______ Cansancio _______ Náuseas. ________ Sensaciones de dolor ______ Comportamiento
perturbador/ mal comportamiento.
______ Ningún síntoma
11. ¿Piensa que su familia se podría beneficiar de comidas del fin de semana? _____ Sí _____
No _____ No sé
5PRE SURVEY- PARENTS
(Nap rasanble enfòmasyon pou nou ka jwenn ki pi bon fason nou kapab ede pitit ou a. Silteplè
ede nou pandan wap reponn tout kestyon nou pral mandew yo. Mèsi. Lèw fini ranpli papye sa,
retounen li ba nou nan biwo lekòl la pa pita ke (The date for returning the paper) .
1. Ki lekòl pitit ou a te pase?____________________________________________
2. Ki zip kòd lakay ou?__________________
3. Ki ras ou ye?
__ Nwa ou byen Afriken Ameriken __ Panyòl/Latino
__ Azyatik __ plizyè ras ou Metis
__ Blan ou Kokazyen __ Ameriken / Pasifika __ Lòt
4. Ki ras pitit ou a sanble?
__ Nwa ou byen Afriken Ameriken __ Panyòl/Latino
__ Azyatik __ plizyè ras ou Metis
__ Blan ou Kokazyen __ Ameriken / Pasifika __ Lòt
5. Konbyen moun kap viv lakay ou?
__ Gran moun (Dizwi tan ou pi gran)
__ Ti Moun (Disètan ou pi piti)
6. Ou pa janm pa genyen manje lakay ou?
____Wi ____Non ______Pafwa _____ Nan Wikenn ou Fen semèn
7. Ou pa janm sote yon repa de fason pou pitit ou ka manje o lye de ou menm?
____Wi ____Non ______Pafwa _____ Nan Wikenn ou Fen semèn
Si repons nan se wi/pafwa, konbyen fwa ou fè sa (sote repa) nan mwa ki sot pase a?
_____ Pi piti ke yon fwa. _______Pi plis ke yon fwa
_____ Pi Plis ke senk fwa _____ Mwens ke senk fwa
8. Eske ou konn strese ou byen enkyetew lèw panse manje lakay ou ka fini avan ou gen lajan
pouw achte lòt manje?
____Wi ____Non ______Pafwa _____ Nan Wikenn ou Fen semèn
9. Pitit ou pa janm plenyen ba ou poul diw li grangou?
____Wi ____Non ______Pafwa _____ Nan Wikenn ou Fen semèn
10. Pitit ou pa janm santi yonn nan sentòm sa yo paske li grangou?
____ Tèt fè mal)_ headache _____ vye konpòtman)_ disruptive behavior
_____ Lestomak fè mal)_ stomachache _____ doulè)_ painful sensations
____ (bouke ou byen kouche)_ tiredness. _____ Anvi vomi)__ nausea
_______ Pitit mwen pa janm gen sentòm sa yo11. Ou panse sa tap fè fanmiw byen si nou
baw yon ti pwovizyon chak fen semen nan via Weekend Food?____Wi ____Non
____mwen pa konne
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