Child And Adult Care Food Program (Cacfp) Participant Enrollment Form printable pdf download

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Institution Name:

Child Food Program of Texas

Agreement Number:

101-0681

Facility/Provider Name:

U Matter Learning Center 403

Child and Adult Care Food Program (CACFP)

Participant Enrollment Form

Your day care facility participates in the U.S. Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP). The

enrolled participant will receive nutritious meals and snacks at no cost to you. CACFP needs verification of enrollment for each participant

in this facility. Please fill out the parent/guardian section of this form, sign it and return it to the above facility/provider. Provide

information for one participant per section. (In order for the institution to receive reimbursement for meals served/claimed, this form

must be completed for each enrolled participant annually.)

Parent/Guardian Please Complete:

Participant's (Child) Name:

Date of Birth:

Age:

Sex:

Male

Female

Date participant enrolled in the facility:

Food Allergies:

If "yes" specify:

Yes

(If the participant cannot be served the CACFP Meal Pattern, a statement from the participant's Health Care Provider must be

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Check Days of Normal Care at facility:

Sunday

Check meals normally eaten at facility:

Breakfast

AM Snack

Lunch

PM Snack

Supper

Evening Snack

Please list the normal times of arrival and departure (check am or pm): Arrive:

Depart:

: You are NOT required to answer this question.

RACE OF PARTICIPANT

White

Black or African American

America Indian/Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

: You are NOT required to answer this question.

ETHNIC IDENTITY

Hispanic or Latino

Not Hispanic or Latino

If participant is an infant (0-11 months), please complete this box, Check all applicable choice(s) below:

formula for infants through CACFP. It is your choice

This institution/facility offers

(To be completed by facility/provider)

whether or not to use this formula based on your infant's needs. Baby foods provided by the institution/facility must be in compliance with the

infant meal pattern as required by 7CFR 226.20.

Today's Date

Please mark your preference

_____________

(choose all that apply)

Birth - 3 months

4 - 7 months

8 - 11 months

I will bring expressed breastmilk for

my infant.

I want the provider to provide the

infant formula for my infant.

I will bring the infant formula for my

infant.

Please list the kind of infant formula

you will bring.

Today's Date

Please mark your preference

_____________

According to CACFP requirements, in order

4 - 7 months

8 - 11 months

to claim meals for reimubursement, the

I want the provider to provide the

provider must provide infant cereal and other

infant cereal and other foods for my

foods when your infant is developmentally

I will bring the infant cereal and/or

ready to accept them.

other foods for my infant.

Note to parents who are getting formula through the WIC Program: Your baby is eligible to get formula from this child care institution/facility as well as from the

WIC Program. It is your decision which formula you want your baby to use when she/he is at child care. If you find you are getting more formula than your baby

needs, you may wish to talk with your WIC nutritionist or your child care provider.

I hereby certify the information given on this sheet is true and correct to the best of my knowledge. I also certify that I was given CACFP Meal

Benefits Income Eligibility Form Letter to Household, the WIC information, Building for the Future Flyers, Civil Rights Appeals Procedures.

Parent/Guardian Signature:

Date:

Print Name:

Address:

City:

State:

Zip Code:

Home Telephone Number:

Date Dropped:

Work Telephone Number:

Emergency Telephone Number:

In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or

disability. To file a complaint of discrimination, write USDA Director Office of Adjudication and Compliance , 1400 Independence Avenue SW, Washington, DC 20250-9401 or call

(866) 632-9992, (202) 260-1026 or (202) 401-0216 (TDD). This institution is an equal opportunity provider and employer.