Virginia Cacfp Meal Benefit Income Eligibility Form For Child Care Centers And Family Day Homes (Page 2 of 3) in pdf

Annual Enrollment Form

Virginia Child and Adult Care Food Program

ONE FORM PER ENROLLED CHILD, NEW FORM MUST BE COMPLETED EVERY 12 MONTHS

This form is required for:

This form is NOT required for:

Child Care Centers, Head Start, Even Start, and Licensed

At-Risk After-School, or Emergency Shelters

Outside School Hours Programs

Center Information - Sponsoring Institutions should pre-fill this section

Joyful-Care Children's Center, LLC

Center Name

CACFP Sponsor Number

Center Address

City

State

Zip Code

PARENTS/CENTERS: This institution participates in the Child and Adult Care Food Program (CACFP) and receives reimbursement to provide more nutritious meals

for your child(ren). Federal CACFP regulations require all parents or guardians to complete or review a CACFP Annual Enrollment Form when enrolling their

child(ren) and 12 months thereafter. This information will help ensure all children receive appropriate meals during their care. The parent or center may complete

Sections 1 through 4. The parent must review to ensure accuracy; then complete Section 5, sign and date Section 6. If parent does not complete

Section 5, center staff should complete to the best of their ability (by observation) and initial the section. The center will review completed enrollment form.

MEALS

DAYS OF

FULL NAME OF

TIMES CHILD NORMALLY ATTENDS DURING WEEK

RECEIVED

WEEK IN

ENROLLED CHILD

ATTENDANCE

(Include Birth Date/Age)

Monday

Breakfast

TIME IN

TIME OUT

TIME CHILD

Tuesday

AM Snack

(check AM/PM and

(check AM/PM

ATTENDS SCHOOL

Child's First Name

record time)

and record time)

(record in/out times)

Lunch

Wednesday

Returns To

Leaves

Time

PM Snack

Thursday

Center

Child's Last Name

After School

Friday

Meal

Saturday

Supper

Date of Birth

Sunday

Classroom

Yes

I work multiple shifts and chil(ren) may be in day care different

Evening

days/hours

Snack

Ethnic/Racial Categories

Please answer both questions. This information is voluntary.

A. Ethnic data of child(ren):

Hispanic or Latino

Not Hispanic or Latino

Mark one only

B. Racial data of child(ren):

Asian

White

Black or African

Native Hawaiian or

American Indian or

American

Other Pacific

Alaska Native

Mark one or more that apply

Islander

Signature and Date (parent or guardian must complete this section)

I certify the information above is correct.

Signature of Parent or Guardian

Date

Parent’s Telephone Number (optional)

NON-DISCRIMINATION STATEMENT: The U.S. Department of Agriculture prohibits discrimination against its customers , employees, and applicants for employment on the bases of race,

color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part

of an individual’s income is derived from any public assistance program or activity conducted or funded by the Department . (Not all prohibited bases will apply to all programs and/or

employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form , found online at

, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information

requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W.,

Washington, D.C. 20250- 9410, by fax (202) 690-7442 or email at program.intake@usda.gov. Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either

an EEO or program complaint please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish). USDA is an equal opportunity provider and

employer.

Child Care Representative Use Only

The effective date can be made retroactive back to the first day the child participates

Effective Date of This Enrollment Form:

in the CACFP as long as it occurs in the same month this form is received.

This form is effective for 12 months from

the date of parent signature.

Signature of Center Representative

Date

Virginia Department of Health

Division of Community Nutrition

Revised July 1, 2014