Approximately 74% of schools in the United States participated in at least one farm-to-school (F2S) activity during the 2022 to 2023 school year. Relationships between specific F2S activities, particularly local food procurement, and health outcomes across multiple levels (individual, family, community, and population) have not been systematically reviewed and reported. This systematic review examined relationships between local food procurement within F2S programs and child, family, producer, and community health outcomes. Secondarily, reported economic impacts and barriers and facilitators to local food procurement in F2S programs were cataloged. Systematic literature searches identified 520 unique records. After title and abstract and full-text screening, 7 peer-reviewed articles and 2 gray literature sources met inclusion criteria, representing 3 cross-sectional, 1 prospective cohort, and 5 quasi-experimental studies. All studies presented individual-level health outcomes and most focused on children’s fruit and vegetable intake. Results suggest local food procurement in F2S programs is associated with increases in children’s vegetable intake, particularly in those with low intake and more intensive F2S exposure, but is not associated with positive changes in fruit intake. Evidence was insufficient to draw conclusions for any other health outcome evaluated at any level. Local food procurement facilitators were program champions, culturally-relevant activities and foods, and family and community engagement. Schools also faced significant barriers related to their ability, capacity, and financial means to source local food. Local food procurement, one of the most common F2S activities in K-12 settings in the United States, is associated with higher vegetable intake among students, but additional rigorous research is needed to determine comprehensive multi-level impacts on student, family, producer, and community health.