APPLICATION FOR MEMBERSHIP (Keep all forms attached to this page) The mission of the Second Harvest Food Bank of Clark, Champaign and Logan Counties is to Target hunger by harvesting resources and partnering to serve and educate our communities. We are responsible for equitable distribution throughout our three county service territory. Recognizing that donated food resources are limited, Second Harvest reserves the right to prioritize potential member agencies based on the type of services provided, the geographic location of the agency, the capacity of the agency and other criteria. The purpose of the application is to provide Second Harvest Food Bank (SHFB) with the information necessary to determine your program s eligibility for membership. Please complete all sections and return to the SHFB with the following: 1.) A Photocopy of your IRS final determination letter which states your 501(c)3 Federal Tax Exempt Status. Please do not send your tax I.D. number (employer identification number) or your state tax exempt letter. 2.) Churches must include either a 501(c)3 letter, and/or a letter from the denomination headquarters stating that the church applying for membership is a church in good standing in the denomination. Independent (non-denominational) churches without a 501(c)3 letter should contact the SHFB for requirements. 3.) The current list of the agencies Board of Trustees or list of the churches deacons or elders, along with the telephone number and address of the board chair. 4.) Any program flyers, annual reports, marketing materials, intake/registration forms and other printed information about the program. Following a review of the application, SHFB will contact your organization with our determination. Agencies approved for membership will also need to complete the following: 1.) A site visit and facility inspection conducted by our Agency Relations Coordinator. 2.) An orientation at the agency location. The contact person(s) for the account as well as key volunteers are required to attend. Mail completed applications to: Agency Relations Department Second Harvest Food Bank 701 E. Columbia Springfield, Ohio 45503 Please call Agency Relations at (937) 323-6507 x 126 with questions about the application process. 1
Second Harvest Food Bank of Clark Champaign and Logan Counties 701 E. Columbia Ave. Springfield, OH 45503 937-323-65074 phone 937-521- 2354 fax www.springfieldshfb.org APPLICATION FOR MEMBERSHIP For Office Use Only: Received Inspection Agency # Date: AGENCY CONTACT INFORMATION Program Name: County: Site Address: City: Zip Code: Site Phone: Fax: Mailing Address: (if different from site address) City: Zip Code: Contact Person: Contact Phone: Email: Billing Contact: Billing Phone: Billing Address: (if different from site address) City: Zip Code: Name of Organization as it appears on checks: Parent or Umbrella Organization (if applicable): Executive Director: Executive Director Phone: Executive Director Address: (if different from site address) City: 2 Zip Code:
SERVICES AND PROGRAMS Our Program is best described as a: Food Pantry (food distribution) Emergency Shelter (temporary or short-term overnight accommodations) Soup Kitchen (meals- no overnight stay) Residential Program (extended stay) Day Care- Child Care Day Program- Adult Care After School Program Seasonal Program (Camp, Holiday Basket Program, etc.) Other Date program started providing services: Description of your Program: Please attach a brochure or brief written narrative Description of Population Served: % Low-Income Served: Description of Geographic Service Area: Eligibility requirements: Referrals accepted from: Days and Hours of service: Indicate AM/PM Sunday Monday Tuesday Wednesday Thursday Friday Saturday 24 hours a day/ 7 days a week By Appointment 3
Storage Facilities: Please Indicate Quantity and Dimensions Dry Storage: (please estimate square footage) How Many? Capacity Refrigerator(s):(please indicate commercial or residential and cubic feet) How Many? Capacity Freezer(s):(please indicate commercial or residential and cubic feet) How Many? Capacity Number and type of cooking equipment in use: What type of vehicle will your organization use to pick up food from SHFB? Program Funding (please be sure percentages total 100%) Private Contributions Foundation Grants Fundraising United Way Endowment/Trust Fees for Service (Day Care Centers, After School Programs, Residential Programs) ( % Sliding; % Fixed) Other (please explain): By signing this application, I certify that our organization meets all the qualifications to receive product from the Second Harvest Food Bank of Clark Champaign and Logan Counties. I further certify that the statements made in this application are true and I have read and understand all of the agreement and agree to abide by the terms and intent of this agreement as a member agency of the Second Harvest Food Bank of Clark Champaign and Logan Counties. Signature of Executive Director Print Name Date 4
EMERGENCY SHELTERS/SOUP KITCHENS Service Statistics: Please indicate the total number of each meal you serve (or plan to serve) per month Breakfast: Lunch: Dinner: Snacks: Average number of individuals served each month: How do people learn about your shelter/soup kitchen? Do you require referrals? Do you receive per diem reimbursement for your clients? If so, how much? What percent are eligible for reimbursement? What other types of services do you provide to your clients? 5
FOOD PANTRIES Please include a blank intake form, if applicable Average number of households served each month: Average number of people served each month: What percentage of your client s access pantry more than 4 times a year? How often may a person visit your pantry? How many days worth of food do you provide? (If your agency pre-packages bags for clients, please include a list of what foods are typically provided.) Does your pantry advertise its services? If so, how? What are your eligibility requirements? Do you accept referrals? Do you require appointments? What is your method of keeping records of clients access to the pantry? Does your agency offer services other than the pantry? How is your pantry currently supplied? What kinds of items do you distribute? Canned Goods and other Non-Perishable Food Clothing tems 6
MEMBERSHIP AGREEMENT SECTION UPON APPROVAL AS A MEMBER AGENCY, (SPONSORING AGENCY) AGREE TO THE FOLLOWING: 1. To serve food directly to clients in the form of meals or emergency groceries, regardless of their race, color, citizenship, religion, sex, national origin, ancestry, age, marital status, disability, sexual orientation including gender identity, unfavorable discharge from the military or status as a protected veteran. 2. To keep accurate records of individuals served, and have established procedures for distribution of food. 3. To inform Second Harvest Food Bank (hereinafter referred to as SHFB) of service levels using the approved forms. Reports are due before the 7 th of each month for the immediately ended month. All signed approved forms and reports must be kept for a period of at least 3 years. If an agency terminates services, all forms will be turned over to SHFB for safe keeping. 4. To NOT sell, trade or barter, or charge any individual for food and know that any item received from SHFB used for these purposes will result in the immediate termination of this agreement between both agencies. 5. To NOT order for other agencies, or use SHFB product for other charitable programs. 6. To use the product received from the SHFB only for the approved program and not banquets, parties, fund raisers, trade, payment for services, or other purposes. 7. If your agency is a Pantry, to provide a minimum three (3) day supply, of three (3) meals per day, to each family member served and to serve clients at least once a month. 8. If your agency is a Feeder, (shelter, soup kitchen, group home, daycare, etc.) to provide complete and nutritious meals, and to have donations for, or the ability to purchase, as needed, items not available through SHFB. 9. To support SHFB by paying a product service fee (as defined in 26CFR Part 1.170A-4A(b)(3) of the Code regulations of the Internal Revenue Service) for the shipping, handling, warehousing, and administrative costs associated with products and to pay all delivery fees (where applicable) for any item delivered by SHFB to our agency. 10. To assume responsibility for the payment of all charges incurred by our agency within 30 days. 11. To notify SHFB, in writing, immediately if; A. The program is altered, or discontinued. B. The authorized ordering person changes. C. The program director and/or agency director changes. D. The program changes location, or undergoes any other significant change. 12. To maintain secure, dedicated, and adequate storage, which ensures the integrity of the food until it is used or redistributed. 13. To obtain all licenses from the State of Ohio, County or Local municipality, if required, as a food service establishment, according to the service provided. 14. To provide a current copy of the 501 (c) (3) non-profit tax-exempt status determination letter from the IRS, or meet the established criteria for an unincorporated church. 15. To provide adequate transportation and personnel to pick up food from SHFB. 16. To permit SHFB to monitor the program, including, but not limited to, having authority to check records, and inspect facility. 7
17. To use all In-Kind Program donations for agency purposes and to serve clients. FOOD RECEIPT AND INSPECTION AGGREEMENT Whereas, The SHFB offered to provide and supply certain food, foodstuff, and related items, as available, to (your agency name), a 501 (c) (3) charity (hereinafter referred to as Donee ); and, Whereas, Donee has warranted to SHFB that all items received will be duly inspected by a qualified member of their staff and found fit for human consumption or they will not be accepted. Therefore, Donee hereby warrants, represents, and guarantees as follows: 1. That the Donee has been awarded the status of a 501 (c) (3) charity. 2. That the SHFB and the primary donors have specifically disclaimed any warranties, or representations, expressed or implied, as to the purity or fitness for consumption of any or all such donated items. 3. That the Donee will adhere to additional donor specifications. 4. That all items accepted from the SHFB are accepted in an as is condition by the Donee. 5. That the Donee will utilize employees or volunteers, having sufficient training, experience, and expertise in the evaluation, handling, preparation, and feeding of donated items to safely and properly judge, handle, prepare and feed those in need. 6. That the Donee, because of the qualifications of its personnel, as above specified, hereby accepts full responsibility for the purity and fitness for consumption of any, and all items accepted. 7. That the Donee will serve/distribute the product as soon as possible, to provide maximum palatability and freshness. 8. That the Donee hereby warrants and guarantees to SHFB, and to the primary donors, that it will hold them harmless from any and all liabilities, claims, losses, causes of action, suits of law or in equity, or any obligation whatsoever arising out of, or attributed to, any action by the Donee in connection with its storage, and/or use of the items supplied to it, by the SHFB. 9. That the Donee will only use the items in a use related to its exempt purpose and solely for the feeding of the ill, the needy, or infants. 10. That the Donee will not sell, offer for sale, transfer, or barter the items supplied by SHFB in exchange for money, other properties, or services. The undersigned certify that she/he has read and does agree to the terms, conditions, and limitations contained in this application. Agency Director/Pastor Title Date Program Director Title Date 8
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