Second Harvest Foodbank of Southern Wisconsin
Member Agency Application
Thank you for your interest in partnering with Second Harvest Foodbank of Southern Wisconsin to end hunger! Please read through and complete the following application. Once we receive your completed application, and proof of your non-profit status, we will review your application. After your application is reviewed, we will contact you to schedule a site visit to your agency. Please allow 1-2 weeks before being contacted by Second Harvest.
If you have any questions about the application process, please feel free to contact us:
Jenny Dalsen (608) 223-9121 x107 or jdalsen@secondharvest.org
Mona Adams Winston (608) 223-9121 x198 or
mwinston@secondharvest.org
Please keep a copy of the completed application for your files!
Please mail original completed applications to:
Second Harvest Foodbank
Agency Relations Coordinator
2802 Dairy Drive
Madison, WI 53718
Membership Information
Welcome to Second Harvest Foodbank of Southern Wisconsin . It is our goal end hunger in Southern Wisconsin . To do this, we collaborate with agencies throughout 16 counties, agencies whose mission includes distributing food to the needy. If you represent one of those agencies, let us find out how we can develop our partnership….
How to become a member agency:
• Either you can come visit us or an Agency Relations representative can come visit you to provide you with information on how we can work together.
• Tour the warehouse. Agency Relations staff can show you what products are available and give a brief overview of how to get the food you need.
• Fill out the attached application information and submit proof of 501 (c) (3) status. Applications are processed January 1 – October 31.
• A site visit by the Agency Relations Coordinator will be set up to assure both parties that healthy and proper food storage and handling is a priority, and that the mission and distribution practices of the agency follow charitable food distribution requirements.
How to use the Warehouse—just the highlights:
• On your first visit, we would like to give your shoppers a tour of the facility. We provide a tutorial on warehouse shopping and give tips on how to best use our warehouse to get the most and best variety of food to people on the least budget.
• Each agency selects employees or volunteers to be registered “shoppers” at the foodbank. Due to the activity of forklifts and other power equipment in the warehouse, we must insist no one under the age of twelve accompany shoppers onto the warehouse floor.
• To ensure opportunities for everyone and adequate food donor activity, some restrictions may be placed on availability of a few items.
• Member agencies are assessed a shared maintenance fee to help cover operational costs of temperature control, lighting, warehouse equipment maintenance and transportation. The current rate is 18¢ per pound of donated items distributed. Certain items at times may have reduced shared maintenance fees. This depends on amount of an item in stock and if that item is perishable, but almost always includes bread, produce, baby food and milk when in stock.
Member Agency Application
General Information
Name of Agency ___________________________________________________
Agency 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 will need a separate site visit before shopping)
Program Name _____________________________________________________
Program Address____________________________________________________
City__________________________________ Zip Code_____________________
Contact Person ____________________ Contact Phone ___________________
Email ___________________________ Program FAX ____________________
Phone Number at Program Location ____________________________________
Billing/Mailing Information
Agency Name _____________________________________________________
Address __________________________________________________________
City ____________________________ Zip Code _________________________
Phone Number ___________________ Fax Number ______________________
Billing Contact Person _______________________________________________
501(c)3 Information (Please Check ONE)
_____ Our agency is a non-profit organization, is not a private foundation or a municipality, and we have our own 501(C)(3) Please attach your 501(c)(3)
_____ Our agency is part of a larger organization (Ex: Salvation Army, YMCA, LSS, Catholic Charities, etc.) Please attach 501 (c)3 of 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
Authorized Shoppers
As agency director or pastor, I give approval for the following individuals to receive food from Second Harvest on behalf of our agency:
Please Limit to Five Shoppers
(helpers need not be listed)
• _________________________________________________________
• _________________________________________________________
• _________________________________________________________
• _________________________________________________________
• _________________________________________________________
Program Information
Our agency is applying as the following (Please Check ONE)
_____ Food Pantry
_____ On Site Meal Program (circle): Hot foods/ Cold foods/ shelf stable snacks only
_____ Food Pantry AND On-Site Meal Program [ you should be using multiple applications]
What geographic area do you serve? ____________________________________
Is service limited to residents of that area?_________________________________
Please indicate the program type/types for which your agency will utilize products from Second Harvest Foodbank. Please Check ALL that Apply
_____ Food Pantry _____ Group Home for Youth
_____ Soup Kitchen _____ Group Home for Disabled
_____ Homeless Shelter _____ Senior Meal Program
_____ Domestic Abuse Shelter _____ Camp
_____ After School/ Youth Program _____ Mental Health Program
_____ Day Care for children _____ Substance Abuse Services
_____ Other _______________________________________________________
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 and/or annual report if possible)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Does your agency require clients to pay and/or do you require or strongly encourage a donation for the food that they receive?
_____ Yes Please describe __________________________________________
_____ No
Does your agency charge clients for other services that your program provides?
_____ Yes _____ No (explain if yes)______________________________________
Does your agency, or do any of its programs, require work or participation in any ceremonies or services as part of receiving food?
_____Yes ______ No (explain if yes) ______________________________________
What are the eligibility requirements for clients to receive food? _________________
What percentage of your clients are low-income? _____________________________
What “standard of need” to determine “hunger” do you use, and how do you determine whether clients meet that standard? ______________________________________________________________________
Do you store and/or distribute food at any location(s) other than the Agency Address?Y/N
Please list each address (turn over if needed) __________________________________________________________________
__________________________________________________________________
What month(s) do you operate food program?
_____ Year Round
_____ January _____ February _____ March
_____ April _____ May _____ June
_____ July _____ August _____ September
_____ October _____ November _____ December
Food Distribution
What are your food programs days and hours of operation?
Monday _________________
Tuesday _________________
Wednesday ______________
Thursday ________________
Friday __________________
Saturday
________________
Sunday _________________
How many families do you serve per month?________________
How many adults do you serve per month? __________________
How many children do you serve per month? ________________ (Actual or estimate?)
How many elderly (65 and over) per month? _________________(Actual or estimate?)
( Attach copy of check-in or data collection form if appropriate)
Food Pantry Programs, Only
Does your pantry limit the frequency or number of times a client can utilize the pantry?
_____ Yes, please explain ___________________________________________
_____ No
How many days of food are given to clients? (Day=Three Meals) _____________
Our pantry:
_____ Distributes pre-bagged food
_____ Lets clients select their items _____ Accounts for family size
_____Accounts for special needs (infants, special diets)
_____Other _______________________________________________________
Resources
What is the main source of monetary funding for your agency? ______________
__________________________________________________________________
From what sources will you continue to receive funding for your agency? ______
__________________________________________________________________
From where do you currently get your food? _____________________________
From what sources will you continue to receive food or funds for your agency?
_____________________________________________________________________
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 manager (if different) Date
Member Agency Agreement Form
Second Harvest Foodbank of Southern Wisconsin : (“Second Harvest”)
Member Agency : Participating meal site and/or food pantry
Primary Donor : Any contributor of food and foodstuffs to Second Harvest
Whereas, Second Harvest Foodbank of Wisconsin has offered to provide and supply certain foods, foodstuffs and related items, as available to
___________________________________________ (Member Agency)
and Whereas, Member Agency has warranted to Second Harvest items received will be duly inspected by a qualified member of Member Agency staff and found fit for human consumption, or items will not be accepted,
Therefore, Member Agency hereby represents and agrees as follows:
• That it is a 501 (c)(3) tax-exempt organization and is currently recognized as such by the I.R.S. Any changes to this status will be reported to Second Harvest Foodbank of Southern Wisconsin within 30 days.
• That the Member Agency serves a population without regard to race, religion, sex, sexual orientation, marital status, age or disability. This population shall consist of at least six persons who receive meals or food packages on a regular basis.
• That Member Agency will provide transportation to pick up food.
• That all items accepted are accepted in “as is” condition.
• That Second Harvest 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.
• In order to assure fair and equal distribution or in response to a primary donor’s request, Second Harvest may limit or restrict distribution to specific uses.
• The Member Agency will utilize employees or volunteers having sufficient expertise, and experience in the evaluation, handling, preparation, and serving of donated food items to safely and properly judge, handle, prepare and serve them.
• That Member Agency hereby accepts full responsibility for the purity and fitness for human consumption of any and all items accepted from Second Harvest.
• That Member Agency will serve the product as soon as possible, to provide maximum palatability and freshness, and will maintain adequate refrigeration and storage space to insure the integrity of the food until used or redistributed.
• That Member Agency hereby warrants and guarantees to Second Harvest and to the primary donor 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 Member Agency in connection with its storage and/or use of the items supplied to it by Second Harvest.
• That Member Agency will use the items only in a use related to its exempt purpose and solely of the feeding of the needy, ill or infants.
• That Member Agency will keep any required records showing goods received through Second Harvest have been given to needy people.
• That Member Agency will neither offer for sale, sell, transfer nor barter the items supplied by Second Harvest in exchange for money, other properties, or services. This includes transfer to other agencies.
• That Member Agency will be monitored by Second Harvest, at least once every two years. Monitoring visits may be scheduled or unscheduled.
• That Member Agency agrees to contribute to the operation of Second Harvest with a shared maintenance fee measured on a per pound basis for food received from Second Harvest.
The Undersigned hereby warrants that he/she is a legally warranted and authorized agent of Member Agency, whose name appears below, and by his/her legal signature does hereby bind it to the terms, conditions limitations, and liabilities of this document.
__________________________________________
Agency Name
______________________________________________________________ Agency Director Signature (Executive Director, Pastor, etc.) Date
_____________________________________________________________
Print Director Name Director Title
______________________________________________________________
Director Phone Director Email
Checklist is Items Needed for Completed Application:
__ Complete Member Agency Application form for each Partner Program (enclosed)
__ Director and program coordinator sign member agreement (enclosed)
__ Include copy of documentation of IRS non-profit status (one of these)
___ 501 (c) 3 letter
____Proof of affiliation with recognized church
___ 14 Point Letter with at least 8 points initialed by church pastor or officer
__ 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.