Intermediate School

1) Child's Name:

2) Age:

3) Grade Level:

Pre-Kindergarten

Kindergarten

First

Second

Third

Fourth

Fifth

Sixth

Seventh

Eighth

Nineth

Tenth

Elventh

Twelfth

4) Teacher:

5) Behavior that demonstrated food insecurity:

(Referral MUST include at least one item in this category)

Rushing food lines

Extreme hunger on Monday morning

Eating all of the food served

Lingering around for or asking for seconds

Comments about nt having enough food at home

Other

6) If other, explain: (optional)

8) If other, explain: (optional)

9) School Performance:

Excessive absences and/or tardiness

Repetition of a grade

Chronic Sickness

Short attention span/inability to concentrate

Chronic behavior that leads to disciplinary action (hyperactive, aggressive, irritable, anxious)

Other

10) If other, explain: (optional)

11) Home Environment:

Often cooks own meal, or have another sibling who does

Moves frequently

Often spends the night away from home (primary residence)

Loss of income

Family crisis

Other

12) If other, explain: (optional)

13) If this child needs to receive extra food, please explain why:

14) Name/title of person referring the student:

15) Date of referral:

Intermediate School

Forms