* Required

MGSD School Nutrition Meal Account Purchase Restrictions

I, the undersigned, direct the following actions be applied to the student identified below. My student has the following purchasing limits on his/her account (list specific restriction ex: no charging, no breakfast, no a la carte, etc.)required

If no charging is indicated above, then when the student does not have the cash to purchase food items, said items can be removed from the student’s possession.

Student Identification:

Student Last Name:required

Student First Name:required

Student Middle Name:

Address:Streetrequired

Address:Cityrequired

Address:Staterequired

Address: Zip Coderequired

Contact Number:(Home, Work or Cell)required

School PIN/PowerSchool Number:required

AGREEMENT: I am the

Identification*

Parent Legal Guardian

of this student and direct that the actions noted above be instituted by Mooresville Graded School District. To implement this waiver, School Nutrition will “flag” the student’s meal account to indicate the purchasing limit. This waiver will be effective upon receipt and upon validation by the School Nutrition Office (normally 5 business days). You must notify our office if you wish to remove any restrictions as they will remain on the account until you do so. This waiver can be withdrawn at any time by either parent or legal guardian by presenting a request to do so to the student’s school cafeteria manager and providing adequate and appropriate identification.

Parent/Legal Guardian Signaturerequired

Email Address: