IMPACT MEALS EMPLOYEE FORM - Van Buren School District

Required

The IMPACT Program helps Van Buren students and families by providing meal boxes during school breaks and other times of need.

VBSD Staff can support IMPACT through a simple monthly payroll deduction or a one-time donation. Every dollar goes directly toward providing groceries for students in our community.

Namerequired

First Name

Last Name

Phone Numberrequired

Email Addressrequired

Schoolrequired

Last 4 SS#:required

Addressrequired

Cityrequired

Staterequired

Zip Coderequired

I authorize VBSD to deduct the amount listed below per month.required

Please note: Payroll deductions will continue automatically each year and do not require a new form. If you wish to change or cancel your contribution, simply resubmit this form and enter $0.00 in the “Monthly Deduction Amount” field. This will serve as your written authorization to stop deductions.

Authorization Confirmationrequired

I confirm that all information provided is accurate, and I understand that this submission serves as my electronic authorization for payroll deduction or donation to the VBSD IMPACT Meals Program.

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The IMPACT Program helps Van Buren students and families by providing meal boxes during school breaks and other times of need.

VBSD Staff can support IMPACT through a simple monthly payroll deduction or a one-time donation. Every dollar goes directly toward providing groceries for students in our community.