Redwood Empire Food Bank : Programs & Initiatives : Partner Organization Application Form

Thank you for your interest in becoming a partner with the Redwood Empire Food Bank. Please fill out the application form below. If you have any questions in the meantime, please don’t hesitate to reach out to Kim Caffrey at kcaffrey@refb.org. We look forward to hearing from you!

Application Document Checklist

❏ Copy of your organization’s IRS 501(c)(3) supporting documents

❏ Copy of linkage documents if your organization’s address is not the actual distribution address

❏ Copy of your current Board of Directors

❏ Partner Organization Application and Agreement, Program Application (via electronic form below, or if you prefer, you may download a PDF form here)

❏ Copy of Food Handler Certificate/Card for onsite Food Program Lead

❏ You may scan/email documents to kcaffrey@refb.org, fax to (707) 523-7901, or mail to 3990 Brickway Blvd., Santa Rosa, CA 95403, Attn: Kim Caffrey

Primary Information

Incorporated 501(c)(3) Name (Required)

EIN # (Required)

Website (Required)

Address

Country

Address Line 1

City

State

Postal Code

Staff and/or Volunteer Information

Individual Responsible for Food Programs – CEO/ED/Director/Pastor/Lead

First Name

Last Name

Title (Required)

Email (Required)

Phone (Required)

Individual Responsible for Billing

First Name

Last Name

Title (Required)

E-mail (Required)

Phone (Required)

Billing Address

Country

Address Line 1

City

State

Postal Code

Person completing Application Name and Title (Required)

Partner Organization Agreement

View Agreement
View Agreement
By applying to utilize the services of the Redwood Empire Food Bank, the Partner Organization agrees to abide by the following Redwood Empire Food Bank policies:
1. The Partner Organization agrees that it meets the IRS eligibility requirements for receipt, transfer and use of donated food under section 170(c)(3). The Partner Organization certifies that it is an established, federally tax exempt 501(c)(3) organization, or wholly-owned by a 501(c)(3) organization or an established church; and it must be incorporated for the purpose of serving the ill, needy or infants (minor children).
2. The Partner Organization may not be a private foundation, even if it has a 501(c)(3) exemption.
3. The Partner Organization agrees that if its 501(c)(3) status is revoked or expires, the Partner Organization will stop distributing Redwood Empire Food Bank products and will notify the Redwood Empire Food Bank immediately.
4. The Partner Organization is required to inform the Redwood Empire Food Bank, without being requested, of all changes to its programs, on either Agency letterhead or via company branded email from the Program’s Main Contact, regarding ALL of the following:
  - Changes in Agency shopper(s), Main Contact for program, On-sight Program Lead, Executive Director/Chief Executive Officer, Recall contacts, or billing contact.
  - Change in location, days, or hours of site distributions, telephone numbers or emails, mailing address, and/or billing address.
  - New food programs the Partner Organization wishes to implement and food programs the Partner Organization plans to discontinue. Failure to provide changes may result in suspension of privileges.
5. The Partner Organization certifies that it will not engage in discrimination, in the provision of service, against any person because of race, color, citizenship, religion, gender, national origin, ancestry, age, marital status, disability, sexual orientation including gender identity or expression, unfavorable discharge from the military or status as a protected veteran.
6. The Partner Organization certifies that it will not collect or exchange fees, donations or services of any kind for products received from the Redwood Empire Food Bank.
7. The Partner Organization certifies that it agrees to distribute Redwood Empire Food Bank food prior to scheduled activities, and will not require client participation, including religious services, in order to receive food.
8. The Partner Organization certifies that it will not use Redwood Empire Food Bank products for fundraising of any kind. Donation cans are not permitted within the area of food distributions, whether the food is from the Redwood Empire Food Bank or not.
9. Partner Organizations may not share, trade, barter, or redistribute Redwood Empire Food Bank products with other Partner Organizations.
10. The Partner Organization agrees to pay charges based on standard Net 30 days terms. Failure to do so may result in suspension of ordering ability or termination of membership. No personal checks.
11. The Partner Organization agrees to regular inspections, both scheduled and unscheduled, as well as monitoring every two years by the Redwood Empire Food Bank as required by our affiliation with Feeding America.
12. The Partner Organization agrees that a key food program staff member will maintain a current CA Food Handler Card or certificate, a copy of which must be provided for Redwood Empire Food Bank files.
13. The Partner Organization agrees that it will only distribute Redwood Empire Food Bank products to programs or individuals residing in their own county of Sonoma, Lake, Mendocino, Humboldt, or Del Norte Counties, unless otherwise stipulated and approved.
14. All items shall be accepted in “as is” condition.
15. The Partner Organization must properly store, refrigerate and handle (in accordance with appropriate Federal, State and local health regulations) Redwood Empire Food Bank products to ensure that these products remain in good condition from the point they are accepted from the Redwood Empire Food Bank until distributed by the Organization, including required temperature controlled transport.
16. The Partner Organization agrees to complete and return Redwood Empire Food Bank surveys and other requested information in the allotted time.
17. The Partner Organization agrees to use Redwood Empire Food Bank products only in a manner relating to the expressed mission and tax-exempt status of the Organization’s food program. No personal shopping is permitted.
18. The Partner Organization certifies that it will abide by federal, state and local law, including all applicable statutes and regulations; and will adhere to additional donor stipulations.
19. Partner Organization must maintain a file of all food bank receipts for 1 year, either digitally or by hard copies.
20. Partner Organizations may not collect Social Security numbers, copy IDs or gather any other sensitive information.
The Partner Organization recognizes that all Redwood Empire Food Bank donations are accepted under the legislative guidelines as outlined in the Bill Emerson Good Samaritan Food Donation Act of 1996 which states that: “A non-profit organization shall not be subject to civil or criminal liability arising from the nature, age, packaging, or condition of apparently wholesome food or an apparently fit grocery product that the non-profit organization received as a donation in good faith from a person or gleaner for ultimate distribution to needy individuals.”

By signing this agreement, the Partner Organization agrees to waive any and all rights it may have in relationship to liability on the part of the Redwood Empire Food Bank, Feeding America and the original donor, for the quality and edible nature of the food it has received from the Redwood Empire Food Bank. Also, the Redwood Empire Food Bank, Feeding America and the original donor will be held harmless from any claims or obligations in regard to the Partner Organization or the donated goods; and the aforementioned will offer no express warranties in relation to the gift of goods.

I, the undersigned, have read, reviewed, understand and agree to the Redwood Empire Food Bank policies as described above. I understand a violation or a loss of confidence on the part of the Redwood Empire Food Bank that the policies or conditions of this agreement are being adhered to may result in the loss of Redwood Empire Food Bank privileges. I understand that this agreement is voluntary and either party may terminate the agreement by notifying the other party.

I have read and agree to abide by the policies of this agreement.

Program Application

Parent Organization that program falls under (Required)

Program Name (Required)

Physical Program Address

Country

Address Line 1

City

State

Postal Code

What is the main focus of this program?

Priority

Check all applicable sub focuses of this program

Other

Describe the purpose of this program (Required)

How does food fit into your program goals? (Required)

Program Main Contact – Onsite Program Lead/Main Shopper for direct communications with the Redwood Empire Food Bank

First Name

Last Name

Title (Required)

Email (Required)

Phone (Required)

Two individuals responsible for product recall notification

First Name

Last Name

Title (Required)

Email (Required)

Phone (Required)

Second Individual

First Name

Last Name

Title (Required)

Email (Required)

Phone (Required)

Service Information

What areas of the county do you serve? (Required)

Distribution Programs

What are your days and hours of distribution? (Required)

How often may people get food? (Required)

Do you deliver food?

If yes, when?

Kitchen/Meal Programs (Meals prepared/cooked, distinguished from snacks)

Which meals do you serve?

Breakfast
Lunch
Dinner
Snack

Number of meals served daily (by day) (Required)

Referral Information – Pantries and Meal Programs only

How are people referred to your program?

Is this site open to anyone?

If no, who is it open to and why?

May the Redwood Empire Food Bank refer people to your program?

If no, please provide reason

Do you require people to call ahead of time?

If yes, phone number and protocol

Do you require any documentation to receive food?

If yes, check documents you require

photo ID
proof of address
proof of zip code
other

(describe)

Health Certificate/License for Kitchens, Meal Programs, Centers, etc.

Are you required to have a Health Certificate or License?

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Certificate/License No

Expiration Date

Statistics – per Month

Total number of households served (Required)

Total number of people served (Required)

Number of Food bags/boxes distributed if applicable

Total number of meals served if applicable

What percent of people served fall into the following categories?

(Each section should equal 100%. A guestimation is accepted.)

Ages

Enter % Ages 0-5 (Required)

Ages 0–5

Enter % Ages 6–18 (Required)

Ages 6–18

Enter % Ages 19–59 (Required)

Ages 19–59

Enter % Ages 60+ (Required)

Ages 60+

Gender

Enter % Male (Required)

Male

Enter % Female (Required)

Female

Enter % They (Required)

They

Disabilities

Enter % Physical (Required)

Physical

Enter % Psychiatric (Required)

Psychiatric

Enter % Developmental (Required)

Developmental

Client Qualification

What client qualifications are required to participate?

Income Range (or enter none) (Required)

Income Based

Ages Served (or enter none) (Required)

Age

Disabilities Served (or enter none) (Required)

Disability

Please Describe (or enter none) (Required)

Other

All Are Welcome (or enter none) (Required)

None

List all Authorized Shoppers – Maximum of 8 per program

It is very important that you keep Shoppers current as your Organization is responsible for invoices shopped by people currently authorized to do so.

Authorized Shopper #1

First Name

Last Name

Phone

Authorized Shopper #2

First Name

Last Name

Phone

Authorized Shopper #3

First Name

Last Name

Phone

Authorized Shopper #4

First Name

Last Name

Phone

Authorized Shopper #5

First Name

Last Name

Phone

Authorized Shopper #6

First Name

Last Name

Phone

Authorized Shopper #7

First Name

Last Name

Phone

Authorized Shopper #8

First Name

Last Name

Phone

Sources of Food by %

Please guesstimate percentages you obtain from each resource listed below. If Costco, Raley’s, Save Mart, Smart & Final, Sprouts, Target, or Walmart—please state which exact location for each store, ie: 10% Target/Coddingtown. Please aim for a 100% total.

Redwood Empire Food Bank %