Certification of Compliance for A.R.S. 15-242.01: Ultraprocessed Foods Prohibition

Local Education Agency (LEA) and Site Details

Information about the Local Education Agency (LEA) and the specific school site(s) this certification applies to.

LEA Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

LEA Website URL

School/Site Name

List all compliant sites below

Site CTDS

List the CTDS number for each site listed above

Certifying Official Information

Certifying Official: An individual authorized by the Local Education Agency, such as the superintendent, assistant superintendent, chief business officer, principal, or other formally delegated administrator, to certify that the information provided is accurate, complete, and compliant with applicable state and federal laws and program requirements.

Name of Certifying Official

Title of Certifying Official

Email Address of Certifying Official

Phone Number of Certifying Official

Certification Statement

By submitting this form, I certify that I am authorized to act on behalf of the Local Education Agency (LEA) and that the public school(s) listed above are in compliance with the Arizona Healthy Schools Act (A.R.S. § 15‑242.01), which prohibits public schools participating in the National School Lunch Program, School Breakfast Program, Child and Adult Care Food Program, and Summer Food Service Program from serving, selling, or allowing a third party to sell ultra‑processed food on the school campus during the regular school day.

Electronic Signature

Typed Full Name of Certifying Official and Signature Date