Milk Order

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Family Information
- Child/ren's Last Name REQUIRED Please fill out this field. Please enter valid data.
- Last Name of Parent Completing Survey REQUIRED Please fill out this field. Please enter valid data.
- First Name of Parent Completing Survey REQUIRED Please fill out this field. Please enter valid data.
- Email Address of Parent Completing Survey REQUIRED Please fill out this field. Please enter an email address.
- Milk Order by Student REQUIRED Please fill out this field.
- Student 1
  - Child Name REQUIRED Please fill out this field. Please enter valid data.
  - Child Grade REQUIRED
    Please enter your child's grade.
    Please fill out this field.
  - Milk Order REQUIRED
    You may order morning snack milk, lunch milk, or indicate no milk for your child.
    Snack White Snack Chocolate Lunch White Lunch Chocolate NO MILK Please fill out this field.
- Student 2
  - Child Name REQUIRED Please fill out this field. Please enter valid data.
  - Child Grade REQUIRED
    Please enter your child's grade.
    Please fill out this field.
  - Milk Order REQUIRED
    You may order morning snack milk, lunch milk, or indicate no milk for your child.
    Snack White Snack Chocolate Lunch White Lunch Chocolate NO MILK Please fill out this field.
- Student 3
  - Child Name REQUIRED Please fill out this field. Please enter valid data.
  - Child Grade REQUIRED
    Please enter your child's grade.
    Please fill out this field.
  - Milk Order REQUIRED
    You may order morning snack milk, lunch milk, or indicate no milk for your child.
    Snack White Snack Chocolate Lunch White Lunch Chocolate NO MILK Please fill out this field.
- Student 4
  - Child Name REQUIRED Please fill out this field. Please enter valid data.
  - Child Grade REQUIRED
    Please enter your child's grade.
    Please fill out this field.
  - Milk Order REQUIRED
    You may order morning snack milk, lunch milk, or indicate no milk for your child.
    Snack White Snack Chocolate Lunch White Lunch Chocolate NO MILK Please fill out this field.
- Student 5
  - Child Name REQUIRED Please fill out this field. Please enter valid data.
  - Child Grade REQUIRED
    Please enter your child's grade.
    Please fill out this field.
  - Milk Order REQUIRED
    You may order morning snack milk, lunch milk, or indicate no milk for your child.
    Snack White Snack Chocolate Lunch White Lunch Chocolate NO MILK Please fill out this field.
- Student 6
  - Child Name REQUIRED Please fill out this field. Please enter valid data.
  - Child Grade REQUIRED
    Please enter your child's grade.
    Please fill out this field.
  - Milk Order REQUIRED
    You may order morning snack milk, lunch milk, or indicate no milk for your child.
    Snack White Snack Chocolate Lunch White Lunch Chocolate NO MILK Please fill out this field.
Terms & Conditions
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:

http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

Mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;
Fax: (202) 690-7442; or
Email: [email protected]
This institution is an equal opportunity provider.

Updated: 10/14/2015
The contents of this guidance document do not have the force and effect of law and are not meant to bind the public in any way. This document is intended only to provide clarity to the public regarding existing requirements under the law or agency policies.
I have read the statement above. Please select this field.

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Milk Order

Terms & Conditions